Seminars in Orthodontics
EDITOR -IN-CHIEF
Elliott M. Moskowitz, DDS, MSd
EDITORIAL BOARD
EDITOR-IN-CHIEF EMERITUS
P. Lionel Sadowsky, DMD, BDS, DipOrth, MDent
Mani Alikhani, New York, NY (2017)
Rolf G. Behrents, St. Louis, MO (2017)
S. Jay Bowman, Portage, MI (2017)
James Caveney, Wheeling, WV (2017)
John Grubb, Chula Vista, CA (2017)
Greg Huang, Seattle, WA (2017)
Robert J. Isaacson, Edina, MN (2017)
Laurance Jerrold, Brooklyn, NY (2017)
Lysle E. Johnston, Jr., Eastport, MI (2017)
Donald R. Joondeph, Bellevue, WA (2017)
Robert G. Keim, Los Angeles, CA (2017)
Richard Kleefield, Norwalk, CT (2017)
Steven J. Lindauer, Richmond, VA (2017)
James A. McNamara, Jr., Ann Arbor, MI (2017)
INTERNATIONAL
Adrian Becker, Jerusalem, Israel (2017)
Jose´ Alexandre Bottrel, Rio de Janeiro, Brazil (2017)
Theodore Eliades, Nea Ionia, Greece (2017)
W.G. Evans, Johannesburg, South Africa (2017)
Jorge Faber, Brasilia, Brazil (2017)
Joseph Ghafari, Beirut, Lebanon (2017)
Vicente Hernandez, Alicante, Spain (2017)
Nigel Hunt, London, England (2017)
Haluk Iseri, Ankara, Turkey (2017)
Roberto Justus, Mexico City, Mexico (2017)
Sanjivan Kandasamy, Midland, WA, Australia (2017)
Peter Ngan, Morgantown, WV (2017)
Perry M. Opin, Milford, CT (2017)
Jae Hyun Park, Mesa, AZ (2017)
Sheldon Peck, Newton, MA (2017)
William R. Proffit, Chapel Hill, NC (2017)
Eugene Roberts, Indianapolis, IN (2017)
Emile Rossouw, Rochester, NY (2017)
David L. Turpin, Federal Way, WA (2017)
James L. Vaden, Cookeville, TN (2017)
Robert L. Vanarsdall, Jr., Philadelphia, PA (2017)
Katherine Vig, Columbus, OH (2017)
Christos Vlachos, Homewood, AL (2017)
Timothy T. Wheeler, Gainesville, FL (2017)
Leslie A. Will, Boston, MA (2017)
Rakesh Koul, Lucknow, India (2017)
Birte Melsen, Aarhus, Denmark (2017)
Antony McCollum, Bryanston, South Africa (2017)
Eliakim Mizarahi, Ilford, England (2017)
Bjørn Øgaard, Oslo, Norway (2017)
Nikolaos Pandis, Corfu, Greece (2017)
Pratik K. Sharma, London, UK (2017)
George Skinazi, Paris, France (2017)
John C. Voudouris, Toronto, Canada (2017)
William A. Wiltshire, Winnipeg, Canada (2017)
Björn U. Zachrisson, Oslo, Norway (2017)
 Seminars in Orthodontics
VOL 22, NO 2 JUNE 2016

Enhancing Communications in Contemporary Orthodontic Practice

Laurance Jerrold, DDS, JD
Guest Editor

■ Introduction 85
Laurance Jerrold

■ Showing you care: An empathetic approach to doctor–patient communication 88

Mitchell J. Lipp, Christopher Riolo, Michael Riolo, Jonathan Farkas, Tongxin Liu,
and George J. Cisneros

■ Communications in moving from hi to buy 95

Benjamin G. Burris

■ Communication by way of the consultation 100

Elliott M. Moskowitz

■ Employee engagement: Communicating clear expectations 103

Gay Lowry

■ How to communicate with orthodontic laboratories 107

Phil Pelligra

■ Communicating orthodontic research via social media 111

Kevin O’Brien

■ How to talk to patients when things go wrong 116

Elizabeth Franklin

■ Stylistic communication and the second opinion 121

Laurance Jerrold

■ Communications as an orthodontic risk management tool 127

Laurance Jerrold
 Seminars in Orthodontics
VOL 22, NO 2
Introduction
W hen I was asked to be the guest editor of
an upcoming issue of Seminars in
Orthodontics, I welcomed both the opportunity
and the challenge. When the Editor-in-Chief
gave me the topic, I was not quite sure why I was
chosen to pursue the assigned theme as I never
fancied myself as having any particular exper-
tise in this area. When I asked him why me, he
responded “if anyone can come up with a dif-
ferent take on this topic it will be you.” Once
again, the duality of opportunity and challenge
came and knocked on my doorstep. I won-
dered, what can one say about the importance
or need for good communication in the arena
of clinical orthodontics that has not already
been said?
The first thing that came to mind was a movie
quote. You all know it. The date—1967. The
movie—Cool Hand Luke. The star—Paul New-
man. The quote is listed as number 11 on the
American Film Institute's 100 Years … 100
Quotes, and was uttered both by Mr. Newman,
but more famously, the one we all remember and
repeat in the same Southern drawl he used, by
Strother Martin. The words—“What we’ve got
here is a failure to communicate.” The context is
universal. The meaning is crystal clear. There is a
disconnect. There is a misunderstanding. There
is a lack of a meeting of the minds between two
people. It is in its simplicity, a failure to
communicate.
As I thought about clinical practice in a more
global sense, I thought about all of the different
venues we find ourselves in on a day to day basis.
We communicate of course with our patients and
all interested third parties; we communicate with
insurance companies and other third party
payers; we communicate with our staff; we also
communicate with our lab; and of course we
communicate with our professional colleagues.
As I thought more about this I realized that we
& 2016 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1053/j.sodo.2016.04.001
Seminars in Orthodontics, Vol 22, No 2, 2016: pp 85–87
JUNE 2016
communicate not just with words, but with feel-
ings and with nonverbal body language. We
communicate subliminally by how we promote
ourselves and how we appear to the world at
large. Language is but one aspect of how we
communicate on a professional level. Thus fail-
ures in communication can occur in a variety
of ways.
This then is the path I chose to explore in this
issue. There is also one other major difference
between this issue and most of the others that
have been published over the years; and that has
to do with the level of evidence that will be
presented. There is hard science and there is soft
science. This issue will deal with soft science.
Almost every contributor to this issue is a
recognized expert in what they do but all have
freely admitted to the art versus science aspect of
this topic and their contribution. Often when
communicating, the words themselves have a
constraining atmosphere. To truly understand
and appreciate the message, one need to only
concentrate on the ideas being espoused as
opposed to the verbiage being committed to
paper. Looking at it from this perspective it
becomes easier to discern the forest from
the trees.
To begin with, Drs. Lipp et al., delve into the
concept of empathy as it relates to patient
communications. They also discuss personal
space and body language. It is these subtleties
that more often than not give truth the adage
that it is not what you say but how you say it that is
really important. I could stress that their article is
a primer on how important it is for the doctor to
get the patient to understand him or her; but that
would probably be a gross miscommunication in
and of itself as well as an understatement. The
better way might be to say we need to commu-
nicate in whatever manner is required to insure
that the doctor and the patient are on the same
page at the same time. Moreover the key to
enhancing the communicative effort is to util-
ize empathetic communication; a technique that
85
86
can be done in a number of ways. What they have
to say is very interesting.
We are not only a profession, but a small
business as well. We have to communicate both as
technical professionals and as entrepreneurs
marketing our services. Personal service is the
most difficult of all services to render to the
masses because it is by its very nature personal,
thus subjective as opposed to objective. Dr. Burris
is quite forthright in his approach to attracting
patients and subsequently getting them to accept
treatment. He forces us to look at who we are and
how we portray ourselves. His submission gets
into the nuts and bolts of how we do, what we do,
and why we do it. From my perspective it is
required reading 101.
Dr. Moskowitz, our Editor-in-Chief, follows with
another perspective on the initial interaction that
leads up to patient acceptance, the consultation. It
is this initial crossroads of doctor patient com-
munications where on one hand information is
delivered and on the other a message is received.
The question of whether it is the message we
meant to send is at the heart of his submission. He
advocates strongly for the two visit consultation as
opposed to the one step. It is a piece of advocacy,
steeped in history, and carries with it a sense of the
importance of transmitting all there is to transmit.
Comparing the two styles of initial approach is of
great importance to anyone who is or con-
templates running a professional business. It, like
Dr. Burris' piece, causes one to think about
branding, of setting a placard in the marketplace
and apprising all of who we are because of how we
do what we do. Having been there and done that
and now having the responsibility for teaching
future orthodontists the ways of the professional
world I find the two approaches fascinating
reading. I urge all of you who do not utilize the
two step approach to consider integrating some of
what Dr. Moskowitz outlines as a means of
enhancing your current one step philosophy and
approach.
The next three submissions are a little off the
proverbial beaten path but they are of major
import because they affect us in ways we do not
often think about. The first is by Gay Lowry. Gay
gets into the nitty gritty of employee commu-
nications. Without our staff functioning at the
highest level, our office and the services we
provide not only do not serve us well, they do not
serve our patient base well. This is critical
Jerrold
infrastructure information that every office
needs to be cognizant of if we are to be suc-
cessful. She covers a breadth of employee
communication considerations from hiring to
firing and all that occurs in between. This is
followed by a piece from Phil Pelligra and it
concerns communicating with your laboratory.
Most of us do not give this a second thought but
we should. Coming from a family of ortho-
dontists, during my summers and school holi-
days, I worked in the lab of my family's practice
making appliances and preformed arches. I am
ever grateful for what it taught me about
orthodontics but I was too young to appreciate
the finer communicative aspects of what should
be going on between practitioner and techni-
cian. Phil spells it out and more. The future of
orthodontic delivery systems will focus more and
more on prefabricated appliances and how
doctors communicate what they want with their
laboratory will be at the threshold of this rela-
tionship. For the younger doctor and for anyone
that does not have an in house lab this is must
read stuff. Finally, Kevin O'Brien discusses using
the social media as a mechanism for commu-
nicating with referring doctors and with
patients. Our world is changing and commu-
nicatively the changes have been greater and
faster in coming than clinical advances in our
field. If we want to play the game, we need to
tools and instruments to do so, and commu-
nicating with our peers and patients is not a
game we can afford to lose. What he does and
how he does it is absorbing reading for those
facing anywhere from a decade to a generation
or two of practice in front of them.
Things do not always go right during treat-
ment. Sometimes we run into problems and
sometimes these problems rise to the level that
they require discussion with the patient. How to
talk to patients when things go wrong is at the
heart of what Liz Franklin, our AAO head of
claims, discusses in her piece. Various cases from
her files are dissected from the perspective of
how to handle the clinical situation; how to
handle your responsibilities regarding interact-
ing with your carrier; and of course, how to
interact with the patient. What we do and what we
say when things go wrong can be the determinant
of whether or not a patient files a lawsuit against
us. Liz's guidance regarding this delicate aspect
of practice is incredibly valuable.
 Introduction
Finally, I have submitted two pieces that
hopefully complete the communications circle.
The first deals with the vexing problem of how to
communicate with patients when facing the
second opinion situation. This is arguably one of
the most awkward conversations that doctors will
have with patients. It also has the potential to be a
major player in terms of being a causative factor
in malpractice suits being filed against ortho-
dontists. Three types of second opinions are
discussed in detail and provide the reader with
step by step sequencing for effective commu-
nication. As most orthodontic programs do not
teach residents the art of providing second opi-
nions, this piece is for residents and seasoned
practitioners alike.
Finally, I have reworked a themed piece on
intra, extra, and interoffice communications that
has been published in various forms in other
journals and texts but has been tailored to
dovetail with the other topics presented in this
issue. It covers various types of communications
along a timeline from pre treatment through
post treatment. It goes into the “whys” behind
many of the forms and letters we use every day in
87
our offices, and discusses them from a risk,
patient, practice and fiscal management per-
spective.
In the end, I hope that the contributors to this
issue have provided a degree of insight into
various communicative methodologies that will
cause you to reflect on how you manage your
clinical environment. Communication and the
lack thereof are vital measuring tools of how well
we are succeeding, or not, in the daily practice of
orthodontics. Our training programs are more
than able to teach us how to move teeth. Where
they are somewhat lacking is in training us how to
move people. While the first concerns itself
heavily with Newtonian physics, the second is
more artistic in nature and requires a subtle study
of the nuances inherent in exchanging ideas and
perceptions with those we treat and those we
work with. If we fail to pay homage to this art,
what we will have is nothing more or less than a
failure to communicate.
Laurance Jerrold
Guest Editor
E–mail: drlarryjerrold@gmail.com
Showing you care: An empathetic
approach to doctor–patient
communication
Mitchell J. Lipp, Christopher Riolo, Michael Riolo, Jonathan Farkas,
Tongxin Liu, and George J. Cisneros

Our College recently convened a series of retreats bringing together faculty,

administrators and employees to identify common concerns. Stakeholders
working independently in small groups separately and collectively agreed
that our major organizational concern was communication. This theme
played out in various ways. From not knowing what was going on beyond an
individual’s immediate work area to broader interpersonal challenges. Some
felt a lack of caring or appreciation. Often the word, “respect,” was used.
Perceived deficiencies extended to students, faculty, administrators, staff,
and most troubling, to patients. Communication skills are recognized as
essential to professional competence by the Commission on Dental
Accreditation, the American Dental Education Association, and the Inter-
professional Educational Collaborative. It is a theme that crosses disciplines
and is foundational to patient-centered care. As scientifically driven evidence-
based healthcare and technologies progress, the emotional, psychological,
social and cultural needs of patients may be neglected. Communication skills
centered on empathy and showing you care, yield benefits to both the doctor
and patient in terms of satisfaction, compliance, and treatment outcomes.
(Semin Orthod 2016; 22:88–94.) & 2016 Elsevier Inc. All rights reserved.

Introduction Education Association, include standards that

emphasize “patient centered care” in a “human-
mpathy is part of being human. Through
E empathy we connect to others and share in
their felt experiences. Science is responsible for a
istic environment.” This article will focus on
the role of empathy in the doctor–patient
relationship.
remarkable transformation in health care. Yet
It is without question that communication
there is increasing recognition that filtering a
skills are necessary to succeed in orthodontic
human being through tests and images and
practice. Many studies in health care suggest that
making objective evidence-based decisions is
communication between the doctor and the
somehow incomplete. The emotional “truths” that
patient positively impacts on satisfaction,
propel people through life have been largely
decreased malpractice claims, and improved
excluded from the process. Health professional
health outcomes.1–4 One article in the ortho-
groups, including The Commission on Dental
dontic literature reported a dramatic decrease in
Accreditation and the American Dental
treatment time when greater attention was paid
to communication.5 While dental and medical
Department of Orthodontics, NYU College of Dentistry, New York,
education programs regard communication as a
NY; Department of Orthodontics, University of Washington School of core competency, it appears infrequently (or is
Dentistry, Seattle, WA; Department of Orthodontics, University of under reported) in the orthodontic literature.
Detroit Mercy School of Dentistry, Detroit, MI. The consequences of miscommunication can
Address correspondence to Mitchell J. Lipp, BA, DDS, Department
be dire, like the 71 million dollar malpractice
of Orthodontics, NYU College of Dentistry, Room 683 W Dental
Center, 421 First Ave., New York, NY. E-mail: mitchell.lipp@nyu.edu
settlement when emergency health care workers
& 2016 Elsevier Inc. All rights reserved.
mistranslated the word “intoxicado” to mean
1073-8746/16/1801-$30.00/0 intoxicated instead of the intended meaning of
http://dx.doi.org/10.1053/j.sodo.2016.04.002 “feeling sick to the stomach” that caused a delay

Seminars in Orthodontics, Vol 22, No 2, 2016: pp 88–94 88

 Doctor–patient communication
in making the correct diagnosis resulting in a
potentially preventable quadriplegia.6
The doctor–patient relationship is deeper
than a transactional relationship. Communica-
tion in this area goes beyond the exchange of
information. Orthodontists need to understand
the complete set of wants and needs of the
patient; often going beyond objective findings in
order to consider psycho-social dimensions that
affect care. Empathy is a discrete and complex
phenomenon that has subtle and foundational
influences in the doctor–patient relationship.
Because empathy affects the information that the
patient discloses, this fact alone may significantly
affect diagnosis, treatment planning, practice
management, and other related skills and
behaviors that lead to a more trusting relation-
ship between the doctor and patient.
Empathy
Empathy is the experience of understanding
another person’s condition from their perspective
by placing yourself in another’s shoes and feeling
what they are feeling. Empathy is known to increase
prosocial (helping) behaviors. Researchers have
differentiated between the two types of empathy.
“Affective empathy” refers to sensations and feel-
ings—an emotional response. This may include
mirroring what a person is feeling, or anticipating
what they may feel. For example, a guttural shriek
when witnessing a person falling and possibly
getting hurt. “Cognitive empathy,” sometimes
called “perspective taking,” is the mental act of
projecting oneself into another person’s per-
spective, and through this process being able to
identify and understand another person’s emo-
tions. In the example of seeing someone fall, this
would equate to appreciating the embarrassment
and frustration that person may feel.
There is some disagreement concerning the
value of affective empathy in training health
professionals. Some feel that by becoming too
emotionally invested in a patients’ personal
perspective, objective based health advice may be
compromised.7 Others stress that the key
component of empathy is the emotional
connection with the patient, and without this
affective bond, behavioral attempts at empathy,
that is, “acting” as if you are really concerned,
would not be as productive.8 Dr. Rita Charon has
advocated the use of narratives, literature, shared
89
stories as methods to reveal the felt emotional
experience of the patient, hence deepening the
empathetic relationship.9
Empathy is rooted in our biology, in our brains
and in our bodies. It has been observed in various
species including rats.8 In the last decade, more
attention has been focused on the role that
mirror neurons play in empathy.10 Mirror
neurons are cells in the brain that fire when
we observe someone performing an action in the
same way that they would fire if we performed
that action. The primacy of mirror neurons in
empathy has more recently been brought into
question. However, their contribution to a
neuronal understanding of empathy remains
under investigation. Empathy is also modified
by external factors such as social–cultural
considerations and socio-economic status.11
A patient-centered environment
Doctor–patient relationships are affected by the
various aspects of the health care process and
environment. These physical and social compo-
nents inherent in this environment begin as early
as the first phone greeting or online contact.
Once inside the physical office, the environment
includes structural elements like location, décor,
furnishings, equipment, cleanliness, order, and
soundscape. This environment is further sup-
ported in part by the entire orthodontic health
care delivery team in that (1) each patient should
feel as if they are the center of the universe with
their wants and needs as the primary focus; (2)
the environment promotes the feeling of safety
and confidentiality; and (3) the staff exhibit
caring and positive attitudes.
Implicit in this team centered office envi-
ronment is a congenial supportive team that
emulates empathetic communication practices.
Effective and empathetic communication is not
only useful in patient management but also in
managing team member relationships. If the
orthodontist intends to lead the team, each
communicative interaction should be designed
to increase awareness of the empathetic role
each team member should display. All of the staff
involved, whether engaged in support services or
involved with direct patient care should be
employing a “Show You Care” communication
style thus reinforcing that the primary concern is
the patient’s welfare.
90 Lipp et al

Table. A Framework for Showing You Care

Attitudes Interpersonal Skills Behaviors

Building Rapport Verbal Giving a direct phone line

Patience Avoid interrupting Making follow-up calls
Respect Avoid too quick of an interpretation Escorting patients
Being fully present Partnership statements Coordinating referrals
Connecting on a Appropriate language Position self in relation to patient
human level (proximity, level, bearing, etc.)
Nonjudgmental Normalizing: recognizing emotional reactions that Introduces names and positions of all
anyone would have health care team members present
Taking patient Giving feedback Establishes an environment of safety
seriously and confidentiality
Cultural competence Eliciting patient concerns Asking permission before touching or
Recognition of Language terminology relating to the patient's illness, intruding on one's privacy or
differences like clearly describing one's condition, the treatment plan personal space
ethnicity or gender, proposed and associated risks and benefits
Cognition Articulation
Humor Vocal placement (timbre, tone, color, etc.), volume, and
size
Tactfulness Pace of speaking
Enthusiasm Varying one's delivery approach (pitch, pace, rate, and
Relating emphasis)
Reflective listening
Provides appropriate wait time after asking questions.
Responding to questions.
Clarifying
Paraphrasing
Acknowledging
Nonverbal
Eye contact
Tone of voice
Body posture
Facial expression
Appropriate touch
Allowing crying
Mirroring patient's body language. Checking for
nonverbal signs (understanding)
Integrations
Integrating verbal with other communication modes
(visual, aural, kinesthetic, etc.)
Note the overlapping boundaries and integration of empathetic skills with other communication skills. In our framework, we
proceed from a theatrical or actor's perspective. Mastering the role begins with understanding the attitudes and attributes of an
empathetic doctor. After understanding the role, we proceed to awareness of the skills required to effectively communicate and
experience/express empathy. Finally these skills need to be integrated and regularly applied in daily living.
 Doctor–patient communication
Despite all good intentions we live in an
imperfect world, largely because we are imper-
fect. Things do go wrong and when they do, it is
essential to acknowledge the fact and move
ahead. Do not hesitate to say, “I’m very sorry this
has happened. We will continue to do everything
we can to resolve (the issues under discussion) as
well as any others that may occur as we proceed
with your care.” The practitioner needs to keep
staff included, supported, and supportive. A team
that shares ownership for the patient’s welfare is
the ultimate goal. Opportunities for training
(and re-training) in communication skills, with
role-playing and scenarios may be helpful. Much
like exhibiting empathy towards one’s patients,
the orthodontist should express the “Show You
Care” communication styles to all team members.
Empathy in clinical practice
Generally, empathy has been studied using surveys
or rating forms in which patients or observers rate
the practitioner relative to response options. Most
scales focus on ultimate outcomes and not isolated
skills or behaviors. One study took a novel approach
by having medical educators work with professional
theater educators that adapted actor-training tools
incorporated in the health care setting12. This tool,
unlike other empathy scales, offered insight into
the observable methods a doctor may use to
improve communication and convey empathy.
From this tool and other sources, we have
attempted to isolate skills and behaviors that are
associated with demonstrating empathy (Table).
If the perspective toward building empathetic
skills stems from the realm of theater, perhaps
the clinical orthodontist should begin by
understanding the role-internalizing core values
like altruism and beneficence; as well as attrib-
utes such as, approachability, nonjudgmental
attitude, and expressing an active interest in the
patient. After understanding the role of the
empathetic doctor, one should then focus on
skills that effectively lead to establishing and
encouraging an empathetic relationship.
Key themes
Educating and communicating
A significant fear for any patient is fear of the
unknown.13 This can be mitigated by calmly
91
explaining things while minimizing technical
jargon, and quickly defining any word which
may cause confusion. Visual aids can be helpful
to demonstrate procedures and appliances and
overcome language barriers. Techniques such as,
tell, show, and do can be very useful for younger
patients. However, overcompensating or over-
using any approach or aid in this area can
become problematic as sometimes the patient
(or parent) can perceive oversimplified
explanations as a form of condescension. Care
must be taken to gauge the mental capacity of the
patient (or parent) possibly using education level
as a guide. Adjusting to match cognitive and/or
language levels of your audience (patient and
parents) is another part of the challenge in
communication.
Orthodontic treatment of younger children
occasionally requires effective communication
not only with the patient but also with the parents
as well. A guiding principle in building empa-
thetic relationships is to strive to understand the
unique needs of each individual and modulate
communication skills and behaviors accordingly.
Active listening
Engage the communication process by first,
asking open-ended questions; and second, by
keeping the number of your interruptions to the
minimum. Allow patients to do most of the
talking. Whenever possible, only interject at
appropriate points, using open-ended questions,
to elicit additional information allowing you to
“funnel down” into more focused questions.
Patients need to feel heard. Ask prompting
questions like “Is there anything else?” or “Tell
me more about that” and then pause to listen to
the response. Phrases such as “I can imagine how
that made you feel,” or even remaining silent can
be effective as long as the patient feels encour-
aged and is assured that she is being heard. If
appropriate, take notes while the patient is
speaking. This conveys the aura of active listening
and supports the patient’s perception of being
heard. Once again, be careful about overdoing it.
Losing focus by taking too many notes can be
distracting and thwart the impression of actively
listening to the patient.
Framing statements convey the intention of
obtaining an accurate understanding.14 Phrases like
“Let me see if I understood everything correctly…”
92 Lipp et al
demonstrate actively trying to understand the
patient’s situation. Giving back to the patient what
you think they have stated not only makes the
patient feel understood but also provides
opportunities for clarification. Listening to and
repeating or rephrasing the patient’s words can
help orthodontists recognize the patient’s feelings
from their perspective.15 It allows the doctor and the
patient to bridge perspectives moving toward
empathy. Patients that feel understood tend to
reciprocate by trusting their health care provider.
The benefits of empathy are tangible and
measurable resulting in improved treatment
adherence, quality of care, decreased health care
costs, and decreased psychological distress.16
Body language
The nonverbal communication an orthodontist
conveys is a crucial element in patient under-
standing and satisfaction.17 In one study, physicians
were asked to disclose medical errors to patients, by
contrasting error disclosure with or without
nonverbal involvement such as, appropriate
touch, personal space proxemics, forward leaning,
body orientation, prolonged gaze, vocal animation,
attentiveness and interest, affirmative head nods, an
numerous other nonverbal communicative
techniques. When nonverbal communication was
absent, physician’s apologies were interpreted as
being less sincere and remorseful.18 The study
demonstrated how nonverbal involvement
facilitated more accurate patient understanding
and assessment of the medical error as well as its
consequences on the patient’s health and their
quality of life.
Body language needs to be open, not con-
strained, and includes such acts as pausing, nodding,
all while maintaining eye contact.14 Starting with
body positioning and hand gestures, creating a
welcoming safe environment for the patient in order
to share information and be made to feel at ease is
important. For example, maintaining focus and
proximity to the patient while leaning forward to
hear the patient’s narratives conveys interest and
helps the practitioner better understand the
patient’s wants, needs, and expectations regarding
treatment.
As noted previously this impression starts the
minute the patient enters the office. Thus the
proverbial “you never get a second chance to
make a good first impression,” starts with how the
front desk staff treats the new patient. Main-
taining eye contact, within a comfortable prox-
imity to the patient, inclined forward to hear
what they have to say conveys interest and not
only helps the listener to really hear the patient
but provides the patient with the feeling that they
are truly being heard. Asking the patient if they
have any special requests or needs is another
mechanism that can be used to enhance their
experience. Whenever the doctor is with the
patient, the patient needs to receive the practi-
tioner’s full attention regardless of other people
being in or near the treatment area. This concept
also includes the idea that whenever possible, the
doctor should not be interrupted by members of
the staff to attend to other needs within the office
until the patient encounter is completed.
Active listening continues by sustaining an
open body position—never appear to be closed
off by folding your arms across your chest.
Respond nonverbally by nodding your head
while remaining engaged in the conversation.
Smiling is a very powerful type of body lan-
guage. Interestingly, but not surprisingly, a
randomized controlled trial demonstrated a
significant negative effect on perceptions of
empathy when doctors wore facemasks while
interviewing patients.19 The orthodontist
should also be aware that some patients may
be anxious just being in a clinical setting, the
so-called “white-coat syndrome,” which has
been found to elevate the patient’s blood
pressure (a key measurement of anxiety).
Establishing an empathetic doctor–patient
relationship can modulate this anxiety.
Match patient’s nonverbal style
Language matters but the manner in which we
say things has been shown to be powerful,
sometimes more powerful than what we actually
say. For instance, one’s tone of voice, volume,
and pacing of speech, all play a role.13 This
paralanguage skill is most effective when used to
mirror the patient’s own tone. In fact, it has been
shown that when practitioners attune to patients
nonverbally, patients feel more comfortable and
give fuller histories.15 Tone should never be
uncaring, apathetic, express frustration, or stress.
Modulating your tone of voice can markedly
modify the patient’s behavior and reduce
agitation; a key factor in managing the child
 Doctor–patient communication
patient. Used pointedly, tone can help the doctor
take charge of a situation, but it must be used in
moderation.
Expressing empathy
Perhaps the clearest way to demonstrate empathy is
to validate the patient’s emotional target. The two
steps in accomplishing this process are first, finding
the target; and second, empathizing with the
patient. An ideal target is one that is close to the
other person’s emotional epicenter. It could be
mirroring back the other person’s rationale of how
they are seeing things and why they feel the way the
way they do. It could be picking up on secondary
elements that they are experiencing which are true,
and offering confirmation of that fact. There is little
empathy in saying “I’m sorry thumb sucking makes
you feel bad.” It’s more empathetic to say “After
hearing that your friends are making fun of you, I
understand how embarrassing thumb sucking is.”
Conclusion
Clinicians should be prepared and ready to
recognize and react appropriately to the emo-
tional needs of their patients by showing genuine
sensitivity and compassion. Empathy must flow
naturally from the professional and his/her staff
to the patient in order to “Show You Care” and
acknowledge that you have a stake in their well-
being.
Unlike other areas in dentistry and medicine,
orthodontics is less frequently an urgent care
service. Patients seek care largely for an esthetic
or quality of life benefit. Being transparent and
bringing financial discussions to the forefront of
the process, engenders trust, pushes aside any
underlying stress, and allows the patient to be
focused during the interview.
Generally, there is a developmental progression
in learning or acquiring new skills and behaviors.
Prior to learning the student or neophyte practi-
tioner is in a state of, “unconscious incompetence”:
ignorance, not knowing or even being aware of
what is not known. As learning begins the novice
becomes aware of their incompetence (conscious
incompetence). Generally, the purpose of dental or
orthodontic training programs is to give the pre-
doctoral or post-doctoral candidate sufficient
experience to become fully aware and competent
(conscious competence). This process continues
93
during the early phases of one’s professional career
and with continually gained experience, by virtue of
practice and repetition, the maturing practitioner
approaches the final phase,” unconscious com-
petence.” This final phase, somewhat synonymous
with expertise, reflects the seamless and facile
integration of knowledge and complex cognitive
and procedural skills without much conscious
effort. Like driving a car—at first it requires con-
centration and effort, after enough practice; it
becomes an almost automatic response. Commu-
nication skills, both verbal and nonverbal, that lead
to empathetic doctor–patient relationships follow a
similar pathway. This essay was intended to bring
this subject of empathetic communication and its
associated skills and behaviors into the practi-
tioner’s consciousness. By developing an under-
standing of this subject the doctor can begin to
apply these concepts and techniques into clinical
practice.
Some of us may recall a time, prior to today’s data
driven era when, “chairside manner” counted.
Considering that empathetic behavior results in
higher patient satisfaction, better patient perceived
outcomes, a lesser tendency for the initiation of
malpractice claims, happier offices, and less doctor
burnout this subject should be given greater
attention in both the educational and clinical
orthodontic environments.
References
1. Clever SL, Jin L, Levinson W, Meltzer DO. Does doctor–
patient communication affect patient satisfaction with
hospital care? Results of an analysis with a novel
instrumental variable. Health Serv Res. 2008;43(5):
1505–1519.
2. Stewart MA. Effective physician–patient communication and
health outcomes: a review. Can Med Assoc J. 1995;152(9):
1423–1433.
3. Korsch BM, Gozzi EK, Francis V. Gaps in doctor–patient
communication. Pediatrics. 1968;42:855–871.
4. Wanzer MB, Booth-Butterfield M, Gruber K. Perceptions
of health care providers’ communication: a relationship
between patient-centered communication and satisfac-
tion. Health Commun. 2004;16(3):363–384.
5. Shelton CE, Cisneros GJ, Nelson SE, et al. Decreased
treatment time due to changes in technique and practice
philosophy. Am J Orthod Dentofac Orthop. 1994;106:654–657
[How do write the name if he’s a “junior”?].
6. Palmer, C. HHS offers cultural diversity guide—miscom-
munication prompts government to enhance national
standards. ADA News May 20, 2013.
7. Newton BW. Walking a fine line: is it possible to remain
empathic physician and have a hardened heart? Front
Hum Neurosci. 2013;7:1–12.
94 Lipp et al
8. Bartal IB, Decety J, Mason P. Empathy and pro-social
behavior in rats. Science. 2011;334:1427–1430.
9. Arntfield SL, Slesar K, Dickson J, et al. Narrative medicine
as a means of training medical students toward residency
competencies. Patient Educ Couns. 2013;91(3):280–286.
10. Lamm C, Majdandzic J. The role of shared neural
activations, mirror neurons, and morality in empathy—
a critical comment. Neurosci Res. 2015;90:15–24.
11. Piff PK, Stancato DM, Côté S, et al. Higher social class
predicts increased unethical behavior. Proc Natl Acad Sci
U S A. 2012;109(11):4086–4091.
12. Dow AW, Leong D, Anderson A, et al. Using theater to
teach clinical empathy: a pilot study. J Gen Intern Med.
2007;22(8):1114–1118.
13. Frenkel M, Cohen L. Effective communication about the
use of complimentary and integrative medicine in cancer
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14. Coulehan JL, Platt FW, Egener B, et al. Let me see if I have
this right…: words that build empathy. Ann Intern Med.
2001;135(3):221–227.
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2003;18:670–674.
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with patient reports of positive physician relational
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17. Larsen KM, Smith CK. Assessment of nonverbal commu-
nication in the patient-physician interview. J Fam Pract.
1981;12(3):481–488[Abstract].
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14:200.
Communications in moving from
hi to buy
Benjamin G. Burris
I t is vital for orthodontists to know how to
communicate well to convert new patients
into paying customers. Having a plan to present
your practice and the service you provide in the
best possible light, while making the process
convenient, fun, and affordable, will maximize
the chance of converting shoppers into buyers.
Moving from hi to buy
Your first contact with a new patient can occur in
a variety of venues but they all lead to the same
place—the prospective patient coming to your
office for the first visit. It is here that various
forms of office–patient communications occur.
Your branding must be tight, your marketing to
be effective and properly directed, your website
and social media presence up to date and pol-
ished, and you must be sure the people who
answer the phone are smiling, patient, infor-
mative and make the right impression. In short,
all facets of your practice/patient interface must
present and communicate specific information
both well and effectively. If not, you will be lucky
to get your new patient to show up for their initial
appointment and if they do you will be fighting
an uphill battle to get them to buy your services.
This article will discuss everything that happens,
or should happen, from the time the patient
parks in your lot to the moment they walk out of
your door.
The arrival
When is the last time you got in a car and pulled
up to your office pretending to be a new patient
arriving for the first time? How easy is it to see
your signage? What does your sign look like?
What do the bushes and grass look like? How
Jonesboro, AR.
Address correspondence to Benjamin G. Burris, DDS, MDS, 2606
Browns Ln, Jonesboro, AR 72401. E-mail: http://drburris.com/
& 2016 Published by Elsevier Inc.
1073-8746/16/1801-$30.00/0
http://dx.doi.org/10.1053/j.sodo.2016.04.003
Seminars in Orthodontics, Vol 22, No 2, 2016: pp 95–99
clean is the parking lot? Are the sidewalks clean?
What does your front door look like? What about
the overall appeal of your facility? Does your
office look like the kind of place you would like to
take your kids to? What do you see when you walk
in the front door and what do you smell? Does
your waiting room look like a bus station in a
third world country or is it clean and welcoming?
What does your decor say about you and your
team?
Have a seat in the waiting room (reception area)
and look around. Look at your ceiling, look under
the chairs, look at the flooring … what do you see?
How does your patient’s bathroom look? Patients
know very little about orthodontics so they will form
opinions as to your ability based on things they do
know about. What messages are you sending them?
Believe it or not this is all a form of subliminal
communication. You are voicing, and quite loudly,
who and what you are or to put it a better way, you
are communicating to your potential patient whom
you want them to think you are. The sliding glass
windows with the matte or mirror finish that sep-
arates your staff from your potential customer does
exactly that, it separates the two of you. You just
cannot afford to have that type of environment in
contemporary practice.
Is there someone at the front desk to greet
new patients when they enter? How do they greet
them? With a smile and by calling them by name
(you know what time the new patient is coming in
and can make a reasonable guess at the new face
being your new patient) or are they met with a
scowl and “the finger”? You know the finger your
receptionist holds up to the new patient who
wants to pay you big bucks for braces while they
hold a phone to their head with the other hand.
You never get a second chance to make a first
impression. Are new patients asked to pay for
their initial visit? I know, we all think our time is
valuable and we want to make sure the patient is
serious and this is why we ask for records fee. The
truth, however, is that our time is worth nothing
if no one is paying us. Actually it is worse than that
—if we are not seeing patients and producing
then our time costs us money because you still
95
96
have to pay fixed overhead expenses. The patient
has already proved that they are serious—they
showed up. The dialogue has already com-
menced without a word being spoken.
After the patient checks in, what happens
next? Do you hand this new patient a clipboard
with a ton of paperwork and tell them to have a
seat until it is completed? This happens way more
often than it should. How does it make you feel
when you go to a doctor’s office and are treated
this way? On top of this supposed administrative
necessity, you now want to charge the patient to
fill out these forms (your initial exam fee).
Really?
What happens next? Is the patient hurried,
unceremoniously, into some room and placed in
a dental chair to await the arrival of the doctor?
What do they see and hear and feel while they
wait? How long do they wait? In most offices the
answer is way too long. What happens when the
doctor arrives? Does he go straight to teeth talk
or does he ease into it and make the patient feel
comfortable with small talk about the patient?
How long is the doctor in the room? What does
the doctor hope to accomplish? What do you
want the patient to think, to feel? Again, all forms
and types of subliminal orthodontic communi-
cation that speaks volumes without saying a word.
What happens next? Do you run the patient
off by rescheduling records until it is convenient
for you to proceed? Do you take records
immediately? Do you proceed with treatment?
How many appointments does it take for the
patient to get started? When do you discuss
finances and how? How much do you require
down and how long do you allow the patient to
pay for braces? What treatment and financing
options do you offer? Are you encouraging the
patient to stay and start or to run out of your
office to consider their options?
The perfect world (according to me)
Let me walk you through how the new patient
visit works (or is supposed to work) in our offices.
This series of events is the result of a decade of
visiting with and learning from the best and
brightest in our profession. Over the years, we
have seen what works and does not and have
constantly modified how we do what we do. I will
do this in outline format so that it is easy to
reference and utilize as a checklist to distribute to
Burris
the team for use as a guideline/point of com-
parison against what you currently do. I know,
“it’s different where you are”—almost every
orthodontist I have ever met says this. I am not
saying that I am right and everyone else is wrong
but if you are not getting the results you want, you
may want to consider other ways of doing things
and if you are convinced the human beings
where you live are of a different ilk then
that makes change and life in general, quite
difficult.
1) The arrival
a) The new patient received an extra-office
communication, an email or snail mail,
with a map from their address to our
office address along with their new
patient paperwork (that we encourage
them to fill out on line or at home).
b) The office signage is clear and well lit and
easily visible from the road.
c) The parking lot is clean and there is
ample parking.
d) The building or part of the building we
occupy is in good repair, looks profes-
sional and inviting.
i) The front door is well painted or
clean depending on composition.
ii) Doctor name is clearly displayed as is
the practice name.
iii) The door is easy to open.
e) The reception area is clean, smells nice, is
uncluttered and inviting.
i) The receptionist stands to greet the
new patient in the language of their
choice—generally English or Spanish
but sometimes another depending
on locale.
ii) The patient is welcomed to the prac-
tice, shown where the coffee, water, etc.
are, where the game room is, where
the restroom is and given a general
idea of how things will proceed.
iii) The new patient paperwork is col-
lected or if they do not have it,
redistributed.
f) The patient restroom is clean, well
appointed and well maintained.
g) All reading material in the reception area
is current and covers a variety of interests
or topics.
 Moving from hi to buy
2) Laying hands on the patient
a) In our office the first person to touch the
new patient is our records coordinator.
i) This position is vital and should be
delegated to a competent experi-
enced individual.
(1) The records person must be
friendly, knowledgeable, effi-
cient, and unflappable.
(2) The records coordinator must
get the minimum records you
require for evaluating a new
patient while answering ques-
tions, providing information
and making the patient and
parent feel comfortable and do
so in a short amount of time.
ii) In our office we take a panoramic
radiograph and a set of 10 intraoral
and extra-oral photos on every single
new patient who walks in the door
(unless they have acceptable and
recent records from elsewhere). If
the doctor needs models, a ceph, or
3D imaging, it is only ordered after
the doctor examines the patient but I
believe it to be impossible to evaluate
a new patient without photos and a
panoramic film.
iii) Once the records are complete, the
records coordinator hands the
patient off to the Treatment Coor-
dinator and gives the TC any insight
gained during the Q&A that occurs
while the records are taken. This
insight is invaluable to the sales
process.
3) The treatment coordinator (TC)
a) The TC collects the patient and parent
and proceeds to show them around the
office to familiarize them with the layout
and people
i) The TC will focus on our people not
our stuff.
ii) Staff members are encouraged to
greet and waive to the new patient
—simply pausing for a second to do
so is sufficient.
iii) The patient is shown the brushing
area and told how that works when
they come for regular visits after
getting their braces on (trial close).
97
b) The TC takes the patient and parent into
a consult room that is designed and built
for this purpose.
i) The TC spends some time going over
the health history, talking about the
problems that the patient and parent
see or the reason that they were
referred to you, talking about expect-
ations and finding out if the patient has
seen or is going to see another practi-
tioner offering to do braces or aligners.
ii) About this time the Records Coordi-
nator shows up with the printed
photo layout and a printed copy of
the panoramic image and gives them
to the TC.
iii) The TC takes the records and leaves the
patient and parent to get the doctor.
iv) The doctor insures that there is
nothing going on in the office that
will interrupt the new patient process
and then turns his total attention to
the TC.
v) The TC gives the doctor the patient’s
background and printed initial records.
(1) The TC shares the patient’s age,
likes, dislikes, fears, hobbies, etc.
(2) The TC shares any info from the
parent about expectations or
about visits to other orthodont-
ists/dentists.
(3) The TC tells the doctor where
the patient comes from and the
reason they came to arrive at our
office.
vi) The doctor does a provisional diag-
nosis and treatment plan right then
and there.
(1) Depending on the type and com-
plexity of the case coupled with
the doctor’s experience, most of
the time this preliminary diagno-
sis and treatment plan can be
constructed from the preliminary
records. The doctor communi-
cates to the TC, in detail, what
issues the patient has, what addi-
tional records are needed if any,
and what the proposed treatment
plan and time frame will be.
(2) This doctor—TC communica-
tion is vital in order to minimize
98
using dentalese in front of
patients and parents because
(1) they do not understand our
vocabulary and (2) it makes them
uncomfortable to be talked
about in ways that they do not
understand and cannot recipro-
cally communicate.
(3) Do not worry if you find you need
to change your diagnosis or treat-
ment plan at a later date after the
acquisition of additional records.
This can often be presented as
enhanced care for the patient
based on additional information
acquired. As you gain more clin-
ical experience this happens less
frequently.
(4) The less dental parlance you use
during the new patient consult
and the less time you actually
spend in the new patient consult,
the more likely the patient is to
start …
4) The doctor meets the new patient and parent
a) In our office we feel it is essential to break
down barriers.
i) The doctor is encouraged to be
friendly and even funny if it is within
his personality to do so.
ii) We do not like the doctor to go
straight at the teeth upon entering
and would prefer that some small talk
and addressing of the human being
be attempted.
iii) We are in the people business work-
ing on teeth, not the teeth business
working on people.
b) We do exams “eye to eye and knee to
knee” as Dr. Dick Barnes has suggested.
i) We find that patients are intimidated
when put into a dental chair.
ii) It is more difficult to do an exam this
way—until the doctor gets used to
utilizing the printed records and used
to doing the exam this way.
iii) If we can do it, you can do it.
c) The doctor talks to the patient and
parent in layman’s terms about what is
going on with the teeth and what we will
do to improve the situation. No
dental talk!
Burris
d) The doctor explains any potential issues,
worries, or possible difficulties that he or
she may see as possible that may be
outside of the normal informed consent
discussion and the TC writes this very
legibly in the appropriate space on the
AAO informed consent form and the
doctor and TC both go over the form
with the patient in series.
e) The doctor asks if there are any questions—
answers any that have to do with teeth and
says, “I don’t know but our TC is an expert”
to any question having to do with money or
insurance and then exits the room.
5) The TC talks Turkey
a) Money and time are always central to
orthodontic treatment and we believe in
getting it all out on the table.
b) We believe in being on the high end of
fees if not the highest in our area.
c) We do not believe in discounting or price
matching.
d) You must have a fee that you and the TC
feel good about—if either of you doubt
the fee then it will show and you will wind
up discounting which is basically admit-
ting that you were lying about your fee
and the patient forced you to tell them
the truth. This is a bad way to start a
doctor–patient relationship.
e) We believe in offering extended financ-
ing and low down payments. See for
yourself at ARsmiles.com.
f) We believe that financing arrangements
and treatment time are wholly separate
issues. Our doctors are not privy to the
account status of patients. We take braces
off when the case is done—no matter
how quickly that happens. This is just part
of our philosophy of treating everyone
like we would treat our own children.
g) We use a combination of LeeAnn Pen-
iche’s and Charlene White’s techniques
along with our own verbiage for discus-
sing financing and signing contracts.
h) We require everyone who opts for in
house, interest free financing to be on
auto-draft.
i) We prefer checking accounts over
credit cards because NSF charges
make our bill a priority but we will
take either one.
 Moving from hi to buy
ii) If people do not want to use auto-draft
then explain to them that they can
have a courtesy for paid in full, use
care credit or a bank. They will not
want to pay interest so just explain
to them that we are giving them a
6000 dollar loan with no interest, no
collateral, and no credit check. 99%
of the time they will understand this is
a sweet deal and agree to the auto-
draft.
6) If the case is straightforward and the patient
is cavity free and has good oral hygiene,
START THE CASE IMMEDIATELY!
a) JUST DO IT.
b) When the staff resists, do it anyway.
c) When it is 4:45 on a Friday and someone
wants to start and there is no reason not
to give them what they want—put the
braces on.
d) It is not about the convenience of you or
your staff.
e) Our office hours are from 8 am until the
last person who wants to give us 6000
dollars leaves.
f) The vast majority of patients see getting
started today as an awesome service.
7) What to do if the patient needs dental work,
hygiene improvement, primary teeth
extracted, or permanent teeth to come in …
a) Do not start the case unless you have a
very, very good clinical reason.
b) Help patients get the care they need so
they can come back and get braces.
c) The idea of needing to start now or
“someone else will treat them” may seem
to make sense but this is bad for patients
and bad for business.
d) If you start only cases that are ready you
will build a solid observation program that
is good for your business and also develops
huge loyalty and a great reputation.
8) If the patient does not want to start today or
sign a contract today for some reason, be
sure to agree upon a time for the TC to
follow up with them.
9) If a patient says they are shopping …
a) Tell them you think that is a great idea
to shop for the best treatment for their
child.
99
b) Offer to give them the records to take
with them so the child does not have to
undergo additional radiation exposure.
c) Being nice and helpful is the way to get
them to choose you.
d) Ask them to return after their other
opinions in order for you to discuss
any differences that might occur.
e) If you do a good job they will never
leave your office.
10) If a patient says they are looking for the
lowest price …
a) We tell them “we are the highest
price in town or close” and that “we
know they will see why after visiting
our office and others” and that “we
think it’s a great idea to shop” and
finally that “we are the most expen-
sive but we offer the best financing so
we are by far the most affordable.”
b) Patients almost always mean afford-
ability when they say they want the
lowest price.
c) People usually want the best car and
the best cell phone and the best
braces they can afford, not necessa-
rily the cheapest.
11) Most importantly, think about things from a
patient convenience and patient comfort
point of view.
Understanding the reality of the orthodontic
marketplace of today means we can no longer
cling to the paternalistic model for healthcare
delivery or do things just because they are easy or
convenient for us. To thrive or even survive in an
ever more competitive landscape we must adapt
and change. In order to avoid joining the race to
the bottom, we must be sure our offices, our
teams, and our doctors convey the value and
quality and fun patients and parents can expect
when they choose us for their orthodontic care.
This conveyance takes the form of paying close
attention to every form of communication uti-
lized in the Hi to Buy process. Some communi-
cations are specific, some are subliminal, some
are vicarious but all are critical. We never want to
be on the wrong end of the saying: “What we have
here is a failure to communicate.”
Communication by way of the
consultation
Elliott M. Moskowitz

Optimizing the consultation appointments with prospective patients or

parents of young patients remain an important challenge in the overall
management of orthodontic treatment. Without doubt, the orthodontic
practitioner requires a profound understanding of the dentofacial character-
istics of each patient who presents for an orthodontic evaluation for the need,
timing, and extent of orthodontic treatment. In addition to understanding the
various components of a specific malocclusion, the orthodontist needs to
continue to hone his/her communication skills to ethically and successfully
inform patients and parents of young patients as to the benefits, risks, cost
benefit ratios, ideal and alternative treatment strategies associated with any
contemplated orthodontic treatment. Intelligently analyzing the specific
components of many malocclusions require a thorough and detailed study
of the patient himself/herself as well as a meaningful scrutiny of orthodontic
pre-treatment records. It is the author’s opinion that a more traditional
approach to orthodontic consultations offer significant advantages over single
visit consultations intended to expedite the entire consultation process with
the obvious intent of immediately starting orthodontic treatment at the
expense of more completely understanding the various underlying compo-
nents of the malocclusion at hand and transmitting this information to patients
and parents of young patients in a more cogent and thoughtful manner.
(Semin Orthod 2016; 22:100–102.) & 2016 Elsevier Inc. All rights reserved.

Introduction same visit. There is probably little argument that

O
ne of the most important orthodontic
office visits is the actual consultation with
patients or the parents of young patients. There
is a distinct difference in the manner that such
consultations are performed in private ortho-
dontic offices in the United States and abroad.
There are orthodontists who prefer to examine a
patient, perhaps obtain a panoramic radiograph
at that same visit, and with this information are
prepared to discuss diagnostic, treatment, and
retention considerations with the intention and
expectation of placing separators (if necessary),
and beginning orthodontic treatment at that very
Department of Orthodontics, New York University College of
Dentistry, New York, NY.
Address correspondence to Elliott M. Moskowitz, DDS, MSd,
Department of Orthodontics, New York University College of Dentistry,
New York, NY. E-mail: typodont@aol.com
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http://dx.doi.org/10.1053/j.sodo.2016.04.004
this protocol leads to more annual patient
treatment “starts” in private practice and elimi-
nates an “unnecessary” extra visit for the adult
patient or parents of young patients. As an
orthodontic colleague once posed the question
(and answer) to me, “when is a person is more
likely to buy a car?; when he (or she) is in the
showroom.” It is hard to take issue with such
practices or perception if patient starts remain as
the top priority in an orthodontic practice. In
fact, it appears that this “one stop shopping” type
of mentality is becoming more rather than less
popular in private orthodontic practice.
It is the author’s belief that the more tradi-
tional approach to an initial examination of a
new patient requires more than a mere cursory
examination and “off to the races” with ortho-
dontic treatment for individual patients. The
author believes that a new patient examination in
orthodontics should include a detailed clinical
examination, initial discussion of the need for
orthodontic treatment, careful attention to the

Seminars in Orthodontics, Vol 22, No 2, 2016: pp 100–102 100

 Communication by consultation
attitudes and chief concerns of patients and
parents of young patients, and obtaining all
pertinent orthodontic records for study before a
more formal and thorough “consultation” visit is
scheduled. Furthermore, that such a structured
protocol (similar to what is taught and practiced
in orthodontic residency programs) provides an
extraordinary opportunity to profoundly benefit
individual patients prior to beginning ortho-
dontic treatment.
A functional checklist of some of the more
important elements of the initial patient exami-
nation and consultation appointment might
include the following:
(1) Review of medical and dental histories.
(2) Note patient (or parental) chief concerns.
(3) General assessment of maxillomandibular
relationships in 3 planes.
(4) Soft tissue examination.
(5) Occlusal and functional exam.
(6) Panoramic radiograph (mandatory, but
especially important in the mixed
dentition).
(7) Discussion with patient or parents of young
patient as to preliminary findings and
general impressions. Does the patient
require treatment? If so, is this the right
time to begin treatment? Is the patient
mature enough to undergo orthodontic
treatment? Should the patient be placed
on a recall list?
(8) Discuss with the patients or parents of
young patients the need to take complete
orthodontic records to facilitate a detailed
assessment, development of a problem list,
and viable treatment options for the
patient’s malocclusion.
(9) Perform a comprehensive examination.
(10) Obtain remaining diagnostic records as
follows:
(i) Cephalometric radiograph.
(ii) Facial and intraoral photographs.
(iii) Study casts (traditional or digital).
(iv) Other diagnostic records, if necessary
(A-P ceph?, CBCT if indicated, and
mounted casts if necessary).
Reappoint for consultation visit
The consultation visit (second visit) is quite a
different experience from visit one and the
101
goals and objectives of this visit differ markedly
from the first initial visit, which entailed an
aforementioned clinical examination, medical
and dental histories, appropriate record taking,
etc. Without doubt, the evaluation of individual
patients and consultation procedures involve a
good deal of both science and art. In addition,
communication skills and the ability to modify
general communication protocols for individual
patients and their parents are important aspects
facilitating the parental or adult patient’s ability
to understand the precise nature of the ortho-
dontic problems at hand.
The author prefers to perform the actual
consultation visit (second visit) with the parents
of young patients for obvious reasons. Young
patients, perhaps requiring more invasive pro-
cedures (surgical exposures of impacted teeth
and associated risks, etc.) will require a com-
pletely different “languaging” at some juncture
than what might be initially discussed with the
parents. This second visit or actual “consultation”
would include but may not be limited to
discussing.
(1) Deviations in patient’s occlusion and den-
tofacial pattern from the ideal.
(2) Are these deviations functional, esthetic,
both, or neither?
(3) The need or lack thereof for orthodontic
treatment (timing of treatment).
(4) Ideal goals and achievable optima for this
patient.
(5) Rationale for selecting particular strategy
(nonextraction or extraction?).
(6) Description of recommended orthodontic
appliances or devices.
(7) Viable alternative treatment plans that
might be appropriate.
(8) Informed consent (risk/benefit ratio of
recommended treatment plans).
(9) Estimated length of treatment and depend-
ent variables.
(10) Patient compliance requirements.
(11) Contingency planning (need for extrac-
tions/orthognathic surgery, adjunctive
periodontal procedures).
(12) Retention considerations—removable or
fixed appliances (problematic areas: rota-
tions, decreased alveolar bone support).
(13) Fees associated with treatment and
retention.
102 Moskowitz
(14) Obtaining patient or parental consent to
begin treatment.
(15) Planning to begin orthodontic treatment.
Patient or parental expectations
Structured and unrushed discussions with
parents of young patients or adult patients can
often establish reasonable expectations of all
parties, which naturally include the orthodontist.
Establishing realistic expectations cannot be
overstated. It is wise to ascertain how patients
might feel about contingency plans and changes
of strategies or devices during orthodontic
treatment prior to beginning orthodontic treat-
ment if possible.
Borderline extraction cases that might require
mid-treatment recommendations for extractions
when patient response or cooperation is unfav-
orable or recommendations for orthognathic
surgery as a result of adverse growth vectors
during treatment might be met with parental or
patient resistance and emotional bias. It is wise to
learn about how parents of young patients and
adult patients feel about such contingency
planning prior to beginning orthodontic treat-
ment even if it means that they will seek another
opinion from another practitioner who will tell
them what they want to hear rather than what
they need to hear.
Orthodontists will be judged only on the care
that they deliver to patients they treat; not the
patients they choose not to treat or those who go
elsewhere for treatment. Well structured,
unrushed, and thorough discussions with pro-
spective patients or their parents during con-
sultation appointments serve as another
screening process to identify patients or parents
of young patients who might not be satisfied with
even the best treatment effort or outcome.
In retrospect, the prime sources of parent or
patient dissatisfaction can be traced to what was
said or not said during the consultation process.
Lastly, much of the consultation discussions
should be memorialized with individually crafted
letters to patients or parents of young patients in
as plain language as possible. Often, critical
points of a consultation may be forgotten and
these communications serve as an important
reminder of what was actually discussed with
respect to expectations, patient requirements,
and risk/benefit factors. The value of these
communications cannot be overstated.
Conclusions
We are experiencing a time when orthodontic
services are in great demand. The introduction
of new technology offering minimal or no visi-
bility of orthodontic appliances has certainly
played a significant role in increasing that
demand. As such, this new era demands more
efforts in patient education than in salesmanship.
Carefully structured consultation appointments
and a honing of practitioner communication
skills will best serve that goal.
Further reading
1. Ceib Phillips, Elizabeth Bennett, Hillary Broder. Dentofa-
cial disharmony: psychological status of patients seeking
treatment. Angle Orthod. 1998;68(6):547–556.
2. Eleanor Thickett, Newton J. Using written material to
support recall of orthodontic information: a comparison of
three methods. Angle Orthod. 2006;76(2):243–249.
3. Moskowitz Elliott. Consultations in the real world. Am J
Orthod Dentofacial Orthop. 2005;127:358–359.
Employee engagement: Communicating
clear expectations
Gay Lowry
P rior to my visits to client's practices and at
continuing education events regarding
employee engagement, I have noticed that there
are several consistent messages coming from
doctors. The top three concerns are as follows:
first, employees do not listen; second, that they
follow new procedures for only a short time and
then revert to old habits or behaviors; and lastly,
they ignore established policies and procedures.
Planning to address these concerns in one of my
lectures, attendees were asked in advance to rate
their employee's level of morale and enthusiasm.
The options for rating were low, moderate, or
high. The results were interesting. In total, 29%
of respondents reported a high level of morale
while 59% of them reported a high level of
enthusiasm. When questioned about the dis-
parity between morale and enthusiasm, the
respondents agreed that their responses were
obviously in conflict with the reality of employee
satisfaction and engagement in the practice.
In 1949, Lawrence Lindahl published the
results of a survey in personnel magazine that
reflected the factors most important to employee
satisfaction. In preparation for a dental CE
course I was giving in early 2105, I tested Mr.
Lindahl's findings. The responses I received
mirrored those in his study in that the most
important issues for employees were a feeling of
appreciation from their employers for their work;
and feeling like they were “in” on things. Tactful
disciplining, job security, and fair compensation
came in third, fourth, and fifth. When contrasted
to what employers believed were the important
factors to their employees, the original Lindahl
study and my duplication of it, showed that
employers believed that their employee's top
concerns were good wages followed by job
security and growth opportunities.
Lowry Consulting LLC, Hoschton, GA.
Address correspondence to Gay Lowry, Lowry Consulting LLC, 7181
Wrights Lane, Hoschton, GA 30548. Email: gay@lowryconsulting.net
& 2016 Elsevier Inc. All rights reserved.
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Seminars in Orthodontics, Vol 22, No 2, 2016: pp 103–106
When presented with the previously stated
information, attendees at another continuing
education program were asked to consider how
can we, as employers who work in very close
proximity with our employees, not know what is
important to them? The answer to that question
was surprisingly simple. It was disparate expect-
ations between the reality of the employees and
the perception of the employer. The root causes
are threefold. First, employers fail to set clear
expectations for their employees from the
beginning. Second, employers often hold
employees accountable even when they have
failed to communicate their expectations with
clarity. And finally, employers do not hold
employees accountable when they fail to follow
established policies or procedures.
At the heart of the problem is a failure to
communicate. As business owners and managers
we assume that information we deem to be
important will filter down and out to the right
people. This is true in both small and large
organizations. As business owners, it is often
easier to communicate a message to a patient
(parent in the case of a minor) or customer than
it is to those whom we employ. It is easier to see
and understand the importance of communi-
cating a consistent message to our patient/cus-
tomer as this is deemed critical to the success of
the business. Yet, in reality, it is the failure to
communicate a clear consistent message to an
employee that is even more critical to the success
of the business, regardless of the business model
or field of endeavor.
Communicating clear expectations for
employees begins before the first interview. This
point becomes clearer when one considers that
the cost of replacing or adding a new employee
can run from $3000 to $18,000 depending on the
type of employee, the type of business, the
training period, loss of productivity, costs of
recruitment, etc., for support level team mem-
bers and up to 150% or more of one's annual
salary to replace a senior management or exec-
utive team member or a doctor. This is not solely
limited to the dental industry; similar information
103
104 Lowry
can be found in research by the Society of
Human Resource Management, on Indeed.com,
and in a Christina Merhar article published by
Zane Benefits in August of 2013.
Pre-employment: The dance
Begin to establish expectations by clearly com-
municating the requirements for any given
position. This is impossible to do if these
requirements are not determined prior to the
search. Too often, we are in a hurry to fill a spot
and miss this crucial step in the process of finding
a candidate that will be a good fit long-term.
Whether using an agency or an advertisement,
the first step is to create a message that clearly
defines roles, expectations, and qualifications. If
the position requires weekend availability, eve-
ning or early morning hours, experience, cer-
tification, etc., these requirements must be
clearly stated. If a number of years of experience
in the field, formal training at an accredited
college or technical school, or proficiency with
specific dental software is important, it should be
stated in the advertisement. Also consider
requesting a cover letter and salary expectations
to be included with the applicant's resume. This
is the first opportunity to determine if a potential
candidate is able to follow directions.
Sample employment advertisement
The following is an example of wording for the
first communication to prospective employees
that needs to be expressed.
Our busy and growing orthodontic practice is
in search of a team player to serve as Front
Office Coordinator. We require a self-moti-
vated, self-confident, multi-tasker who under-
stands clearly that the patient is the focus of
our business. The right person should have 3
to 5 years of experience in the medical/
dental/orthodontic setting, be an excellent
communicator, friendly, patient, and have
experience with (state the specific practice
management software you are using if that fact
is critical). The candidate person must also
have an extensive knowledge of medical/
dental/orthodontic insurance.
Duties will include, but are not limited to,
answering phones, making appointments,
gathering accurate demographic and insur-
ance data, being an advocate for the patient,
parents, and referring dentists/doctors, and
be willing to step into any role for the benefit
of the patient and the overall success of the
practice. Accuracy in data gathering and input
is critical.
Interested applicants must submit a cover
letter detailing why they should be considered
for an interview. The letter must also state the
applicant's current salary as well as salary
expectations. References will be checked
and honesty and integrity will be crucial.
Resumes received—What is next
Most practitioners assume that once resumes
have been reviewed, it is time to schedule per-
sonal interviews. STOP! The two steps that ulti-
mately save most of the time and money are the
phone interview and contacting previous, not
current, employer references. Most doctors and
managers prefer to skip these steps and move
straight to setting up interviews. One might ask,
“Is this really necessary?” The answer is a
resounding YES! This phase of the process will
save the business owner, mid-level management,
and the support teams an immense amount of
time and money from training someone who
eventually turns out to be a bad hire. The pur-
pose of these initial steps is to pre-qualify every
candidate. Based on my experience, falsified
resumes range from 50% to 70%. The most
prevalent false data include incorrect employ-
ment dates, educational history, job title, and
compensation. Your due diligence is to verify to
whatever extent possible the facts stated in a
candidate's resume. Use all of the tools available
in the screening process including social media
sites like Facebook and LinkedIn. Consider
whether the entries found reflect the character
of an individual that will represent your business
in a positive light.
Considering that a very high number of
resumes have errors or falsified information, the
next step, before contacting the potential can-
didate, is to contact previous (not current)
employers listed on the resume. Do not call the
names or phone numbers listed on the resume. A
quick search on the internet to find the previous
employer's name, address, and phone number is
the first step. Place the call to that employer using
 Employee engagement
the information that you independently gathered
instead of the contact information supplied by
the candidate. Ask for the doctor or office
manager, only stating the reason for the call if
asked. Many times a prospective employee will list
former coworkers, previous employees or friends
as the contact reference in the office. The fol-
lowing is a list of questions to ask during the call
to the previous employer:
(1) What were the dates of employment for the
candidate? Do not offer the dates listed on
the resume as those may have been falsified.
(2) What was the title and level of responsibility
of the candidate?
(3) Is employee eligible for rehire?
(4) Did the candidate leave voluntarily?
Following the calls to the previous employers,
the list of potential candidates often becomes much
shorter. At this time, it is appropriate to make the
initial contact with the potential candidate.
The initial contact with any potential candidate
is an important screening tool. If the potential
candidate answers his/her cell phone during
business hours when he/she, according to the
resume, should be at work this should exclude the
candidate from consideration. Keep in mind this
person will exercise the same behavior in the next
practice they work in—your practice. In the event,
during the initial contact, the potential candidate
states that they are not at work, the questions to ask
is why. In the event the answer is “I am no longer in
my former position,” the candidate should be
dropped from consideration as they have just
showed themselves as being untrustworthy.
The initial phone interview should be short
and to the point. The following are the questions
to ask the candidate:
(1) Why are you searching for a position at
this time?
(2) What are your current responsibilities?
(3) How long have you been in the current
position?
(4) What days and hours do you currently work?
(5) When are you available for an interview?
(6) If you were to accept a position with us, what
length of notice would you need to give your
current employer? If the answer is less than
2 weeks this is not an acceptable candidate.
105
For an office managers position the expect-
ation should be 3–4 weeks for an appropriate
notice period. Again, if they would leave
their current employer without adequate
notice, they will do the same to you when
and if the time comes.
The dreaded interview process
During this phase of the process, communicating
expectations clearly will determine the success or
failure of the relationship. Do not delegate the
entire process to a manager or support person. It
is your practice, therefore the practice owner or
managing partners must be involved. Other key
members of your team should also be involved in
the interview, preferably as a group. This will help
to determine if there is good chemistry between
the leadership team and the candidate. If the
chemistry is wrong or if there are any doubts, it is
time to take a step back and consider other
candidates.
Other than the typical interview conversation,
there are a number of other questions that
specifically relate to setting expectations and
measuring the fit of the candidate to the position.
Consider posing the following questions:
(1) Would you be willing to authorize a criminal
and credit history background check?
(2) Will you be available for a working interview?
(3) Is there any reason you would require time
off during the first 6 months of employment?
Why are these questions important? A recent
DUI, a criminal conviction for theft, a bankruptcy,
foreclosure, unpaid medical bills, or student loans
offer a different picture of how the potential
candidate will or will not fit in the practice culture.
Regarding the question that asks about “time off
in the first 6 months,” it is very common for a new
employee to accept a position and begin work only
to request a few weeks after starting that he/she
needs time for a pre-planned vacation, family trip,
wedding, etc. If this is disclosed in the interview
phase, there is ample opportunity to decide if this
will work for the practice.
Candidate identified—What is next?
The decision has been made; the offer extended,
the working interview was successful, skills tests
106
were excellent, background investigations
(criminal, credit, and employment) were com-
pleted, and the candidate has accept the verbal
offer. Now what? It is at this juncture that the
need for clear, concise, and specific communi-
cations must occur at an even higher level. At this
point the employer should proffer a letter of
intent or offer letter. This is not a contract and
the offer letter should state this clearly. The letter
serves as the next step in the communications
process and is used to clarify expectations in
writing before the candidate begins work. The
letter must be specific about issues that are
important to the practice. If uniforms are not
provided, clearly define the dress code for the
position. The letter should further state the
starting date of employment, expected work
schedule, the salary, benefits offered, date of
eligibility for benefits, and other information
important to establishing clear expectations on
the part of the employee. If during this in-hire
process, policies are not clearly defined, practices
are far more likely to onboard employees that will
not be a match for the practice culture or meet
the practice owner's expectations.
Maintaining expectations
Communicating clear expectations is an ongoing
process. Regular performance reviews, preferably
not tied to salary reviews, are critically important.
The main purpose for them is to provide the
feedback required for employee satisfaction.
Employees need and want the feedback of the
practice owners and management; it is important
to them.
Use morning meetings or huddles to set the
expectations for the day. Regardless of the size of
your practice, this is a valuable tool. If huddles or
Lowry
staff meetings are not conferring a benefit for the
practice, consider seeking out someone to coach
the owner or leadership team through this
process.
Avoid making blanket statements in meetings
when the topic or issue relates to a specific
person or persons in your employ. If criticism is
made to the group, you can be certain that the
person to whom the comments were directed will
not recognize the message as having been tar-
geted to them. Those who are not in need of the
improvement or change will likely feel they have
been unjustly criticized. Blanket corrective mes-
sages are an avoidance tactic; they rarely work,
and are an example of poor and unclear com-
munications that business owners and leaders
must avoid. Worse, it makes the speaker
appear weak.
Be encouraged
Everyone makes missteps in communicating
effectively. Be encouraged and motivated by the
fact we can all learn, develop, and improve our
communication skills to create a positive working
environment for everyone. As we take steps to set
clear expectations and improve our communi-
cations, our employee's satisfaction, morale, and
level of engagement improve. When employees
begin to feel included and informed, and when
they have the opportunity to provide input, they
tend to take a greater sense of ownership. This
greater sense of inclusion leads to enhanced job
satisfaction and it also creates an attitude of
loyalty to both the mission and vision of the
practice owner. Remember the old adage. It s not
enough to just talk the talk, you need to walk the
talk as well.
How to communicate with orthodontic
laboratories
Phil Pelligra

The purpose of this article is to help improve the relationship between the
orthodontic practice and their laboratory vendors. It seeks to provide ideas
and suggestions on how to achieve this goal by knowing the right questions
to ask your laboratory vendors. Improving dialog ultimately leads to a less
stressful and more positive business relationship. The lack of quality
communication with vendors is a common problem in business, as well
as with many orthodontic practices. This article will provide the orthodontist
with tips and direction on how to improve on your current laboratory
communications and will outline specific questions to ask your current and
prospective vendors. The goal is to make your life easier and more productive
by saving the practice time and money. (Semin Orthod 2016; 22:107–110.)
& 2016 Elsevier Inc. All rights reserved.

Background and discussion a good working relationship. As professional

O
technicians, we continually strive to maintain a
ne of the many essential components to a
low remake factor. We hone our skills and take
successful orthodontic practice is good labo-
the latest laboratory related continuing educa-
ratory communication. Clarity in communication is
tion courses. Our ultimate goal is to give our
critical at a time when all practices have to reeval-
clients and their patients the best possible
uate every aspect of their business. Communicating
appliances at competitive costs.
well will ultimately save time and money by making
Many doctors have expressed the feeling that a
your business model more efficient.
contemporary orthodontic practice is, to some
Without open communication and a solid
degree, a field of narrowing control. The labo-
working relationship in place, appliances may be
ratory relationship is one area in which the doctor
made incorrectly, resulting in time consuming
still has control, take advantage of it. The fol-
chairside adjustments, or even the need for
lowing are recommendations when establishing a
complete remakes. This in turn may ultimately
working relationship with a laboratory partner:
result in delays in appliance insertions, appoint-
ment cancelations, additional cost, and in
1. Establish a primary contact person (PCP) at
extreme cases, even lost patients. The resulting
your lab. There should be one key person
frustration and stress to you, your staff, and
with whom you communicate regarding
patients is a major concern in trying to run a
laboratory issues and concerns.
successful business in today’s competitive ortho-
2. Establish your design standards up front for
dontic environment. The orthodontic laboratory
your retention appliances of choice. You may
industry average for remakes is 2.78%.1 In my
have different retainer designs for different
experience, labs that are below a 1% remake
types of cases such as extraction versus non-
average achieve this benchmark because of open
extraction. Ask the lab to keep a “Client
and consistent communication with their clients.
Preference Card.” This will provide a basic
Remakes reduce profit and are not conducive to
reference for routine appliance designs, wire
gauges, acrylic trim styles, acrylic colors, and
Perfect Finish Ortho Lab, Inc., Hackettstown, NJ. expansion appliance preferences.
Address correspondence to Phil Pelligra, BS, BA, Perfect Finish 3. Know what your laboratory’s normal turnaround
Ortho Lab, Inc., 101 Bilby Rd., Unit F, Hackettstown, NJ 07840.
E-mail: philpelligra@hotmail.com
time is for appliance fabrications. If there is the
need for a rush on a case, make sure you know
& 2016 Elsevier Inc. All rights reserved.
1073-8746/16/1801-$30.00/0 your lab’s requirements for doing so and
http://dx.doi.org/10.1053/j.sodo.2016.04.005 whether or not there will be any extra charges.

Seminars in Orthodontics, Vol 22, No 2, 2016: pp 107–110 107

108 Pelligra
4. If your PCP has delegated responsibilities in
various areas within the lab, and conversely
you have a designated person in your office
who deals with lab related issues, make sure
the individuals within both businesses who
are responsible for answering technical ques-
tions, placement date concerns, and billing
inquires have been identified to each other.
Exchange extensions and emails of all
responsible parties. Alert your lab partners
if any staff changes occur to ensure that the
lines of inter-business communications
remain open.
5. Make sure you know your lab’s warranty
policies for appliances (wires, acrylic, solder
joints, etc.).
6. Ask about sterilization/infection control pro-
cedures. It may come up regarding OSHA
compliance or through a patient inquiry.
7. Inquire about lab closure times and policies
for holidays, vacations, training, or bad
weather days. Log these dates into your
appliance scheduling book.
8. Find out how long your lab retains the
prescription sheets. This may have practical
as well as administrative law related concerns.
9. Ensure your lab has the ability to use hypo-
allergenic wire (nickel free) and acrylic (methyl
methacrylate free) for patients presenting with
a history of allergies to these materials.
10. Make sure you know how much total expan-
sion your preferred expansion appliances
have, and what the turning ratios are (turns/
mm).
11. Find out what your lab’s remake policy is and
request a copy of it.
12. Finally, ensure that your Business Associates
Agreements are up-to-date.
There are proper procedures for filling out a
lab requisition/prescription form (Rx). It is best
to draw the design out on the Rx form as well as
fully writing out the instructions. If your drawings
are not legible, then only write out the instruc-
tions. A sloppy drawing or slip of the pen may
look like a clasp or finger spring to the techni-
cian. The following figures demonstrate an
unclear prescription (Fig. 1) followed by the
corrected identical prescription (Fig. 2).
1. In this example, the Dr. is asking for a Lower
Spring Aligner, however neither the type nor
style is specified and the number of teeth to be
reset teeth is unclear. The Hawley description
asks for 3–3 Labial Bow but the drawing
appears to indicate that the bow is to be
soldered to the Adam’s clasps. In addition, the
finger spring request is unclear on both
direction and type. Finally, the placement
date has been left blank.
2. In this Rx, a lower Modified Spring Aligner is
requested with the set-up clearly indicted. The
design of the upper Hawley bow is clearly 3–3.
The finger spring direction and one coil
design is stated. A specific acrylic color is also
requested. The placement date is conspicu-
ously noted. In short, the prescription is fully
completed.
Ancillary considerations when completing a
prescription are
 Do not use gel pens. They bleed or get washed
out and become unreadable when the Rx
gets wet.
 Agree on the same designation/notation for
identifying teeth, Palmer v. Universal. Don’t
ever mix the 2.
 If not providing a laboratory analog for T.A.D.
fabrication, clearly mark the cast for T.A.D.
location, not the Rx.
 In any deep bite case or situation where
anterior teeth will be reset, always send a
counter.
 When placing pontic teeth in an appliance
make sure to specify the correct shade desired
and provide a counter for occlusal reference.
Use your lab as a resource and a vehicle for
feedback. Many labs see hundreds if not thou-
sands of cases a month. Tap into that resource for
the availability of new products and appliances
that you might have heard or read about. You
may want to incorporate some of these adjunctive
appliances into your practice. Before trying a new
product or appliance, ask your laboratory about
what they have experienced and what type of
feedback they have received from other practi-
tioners they service. A phone call could save you a
lot of time and money as the lab may have
received negative feedback from other doctors. I
speak to accounts daily on a variety of topics such
as software, intraoral scanners, adhesives, and
expansions screws. I have the advantage of seeing
 Lab communication 109

Figure 1.

the before and after casts of patients. Ortho-
dontic labs have the advantage of prospective
hindsight as over time they get to see which
appliances function well and which ones do not,
be they fixed, removable, or functional. Labs
often see the clinical contraindications associated
with many appliances. In a joint survey of 5000
dentists nationwide, 70% indicated that better
communication was the most important feature/
service they look for when choosing a
laboratory.2
Because of my business relationships, many of
which are orthodontic training programs, over
time I have seen a growing trend of orthodontic
programs de-emphasizing the laboratory aspect
of orthodontic practice. In short, appliance
design and appliance fabrication are becoming
increasingly less important relative to the

Figure 2.
110 Pelligra
curriculum. Without such training it becomes
even more important that the appliances are not
only designed correctly by the practitioner, but
made correctly and accurately at the lab because
the orthodontist may not be equipped to adjust
or repair the appliance properly. This is another
example of the need for strong communication
between office and lab.
A new area regarding communication consid-
erations is 3D digital technology. If you are
entering into the field, or are already using it, you
are finding out about the learning curve asso-
ciated with software, data storage, and trans-
mission. Before purchasing intraoral scanning
equipment have discussions with your lab to make
sure files and software are “open files” and not
proprietary closed files that may prohibit you from
using them as you choose. Ask the vendors if they
offer assistance with staff training as it relates to
data transmission with your lab. Digital impres-
sions will result in fewer remakes and better fitting
appliances as models that are created from using
this technology are extremely accurate.
Another new development in the area of
digital communications that some orthodontic
labs are beginning to use is smart phone tech-
nology. In the past, if we had an unclear Rx or
cast, we would have to call the orthodontic
practice and try to communicate over the phone
what our concerns were. At times, it was quite
challenging to describe a possible impression
distortion or unclear prescription drawing over
the phone. The Dr. or staff member is at a dis-
advantage without the visual aid in front of them.
With the smart phone we are able to take a clear
photo of the area in question and email or text it
to the interested parties. They are then able to
make a better decision on how to proceed as they
now have the same information that the lab has.
For offices that are using this advantageous
communication tool, it has saved a lot of time and
frustration; negative aspects in the laboratory
part of practice that have in the past been con-
sidered an unfortunate part of doing business.
Providing direct email and cell phone numbers
to your lab partners often make the lines of
communication more positive, productive, and
profitable.
Make your lab part of your team. They can
help you with the success of your practice. Good
communication will save you time and money by
creating a better and more productive business
environment.
References
1. Marsico M. The remake debate. Lab Management Today;
March: 6–8, 2011.
2. Carr K. What do dentists want from you? Lab Management
Today; February 6–11, 1994.
Communicating orthodontic research
via social media
Kevin O’Brien
n this article, I am going to share my personal
I viewpoint and knowledge on how to com-
municate orthodontic research via social media.
This is based upon many years experience of
involvement with computers and recently writing
a surprisingly successful orthodontic blog. Like
many people, I have used the Internet extensively
in my work as an academic orthodontist, it is
recently that I have become aware and made use
of social media in obtaining and disseminating
research knowledge. This article is, therefore,
not based on any science; it is only my personal
experience and other low levels of evidence. I am
not going to reference any sources in this article
because they are all available using an electronic
search. This is an article about contemporary
communication, which while having few re-
straints has great importance when considered in
the realm of orthodontic communications. It is
also difficult to write an article on social media
because knowledge of this field is closely asso-
ciated with age. This is because the younger
generation of orthodontists will have grown up
with the rapid developments in social media. As a
result, I shall set this article at the level of
someone who has minimal experience of this
continuously changing area. Finally, I will only
discuss platforms with which I have experience. I
will start with Twitter.
Twitter (it is not all about lunch….)
It is difficult to describe Twitter and the best way to
think about it is as a social messaging site, which is
based around sending short messages using a very
limited number of characters. All messages are
confined to 140 characters and are called “tweets”.
It is designed to be a method of quickly and easily
School of Dentistry, The University of Manchester, JR Moore Bldg,
Manchester M13 9PL.
Address correspondence to Kevin O’Brien, BDS, FDS, MSc,
DOrth, PhD, School of Dentistry, The University of Manchester, JR
Moore Bldg, Manchester M13 9PL. E-mail: Brien@manchester.ac.uk
& 2016 Elsevier Inc. All rights reserved.
1073-8746/16/1801-$30.00/0
http://dx.doi.org/10.1053/j.sodo.2016.04.006
Seminars in Orthodontics, Vol 22, No 2, 2016: pp 111–115
communicating a message to a lot of people. All
those who read your tweets are called your “fol-
lowers.” Each tweet can also be linked to an image
or to a website that contains the information that
you want to highlight. Tweets, therefore, can be
linked to publications that you feel are important
or ones that support your message or philosophy.
Suppose for example, an article was just published
relating to the long-term care and responsibility of
lower lingual bonded retainers. Suppose this
article highlighted that long-term responsibility
for oversight and maintenance of such a retainer
was within the prevue of the general dentist.
Finally, suppose that the article contained step by
step instructions detailing how to evaluate the
efficacy of the appliance, the maintenance both by
dental practitioner and patient, and the repair of
this type of retainer if necessary. You might decide
that Twitter is an excellent mechanism to make
the citation of this article available to all of your
referring dentists.
In December 2014, Twitter had 500 million
users. People can send and receive tweets by
phones, tablets, and computers. It is, therefore,
highly mobile and reactive. While the popular
use of Twitter can be classified as inconsequential
chat, for example, elaborating on “what you had
for lunch”, it is also used extensively to share
information and this is where it has a use in
dissemination of research.
There are many organizations, journals,
researchers, and research opinion leaders who use
Twitter to express their opinions on current
research and to also highlight research findings
and recent publications. My sources of information
tend to be United Kingdom based but it is worth
looking at and following such authorities as Hilda
Bastian (@hildabast) who also writes a great blog
called statistically speaking, Trisha Greenhalgh
(@trishgreenhalgh) a UK-based medical researcher
who constantly poses questions on evidence based
care and Iain Chalmers founder of the Cochrane
Collaboration (@iainchalmersTTi). He does not
tweet much but when he does it is important and
interesting. There are many others and I find them
invaluable in keeping up to date with research.
111
112 O’Brien
When I consider actually sending tweets,
Twitter is a great way of communicating infor-
mation. However, it is important to take great
care and work on writing good tweets. Essentially,
you need to be brief and “to the point.” This is
because you do not have a lot of space; only 140
characters. The best tweets are conversational
and informal and provide straightforward
information. If you want to explore this further
there has been a vast amount of research on the
use of twitter, the best time to send tweets and
other complex uses. This can all be found using
standard internet sources such as google, etc.
I run my own Twitter account and I use it
mostly to disseminate information about my blog,
I also obtain information on newly published
research articles and send this on to the people
who follow me. I find it very useful and if you do
not have an account, I suggest that you should
open one, find some people to follow and only
tweet when you have something interesting to
say. There is nothing wrong with not tweeting. In
the fine art of communicating, aural ingress is
often far more useful than oral egress.
Blogs
This is an area in which I have a reasonable
amount of experience (www.kevinobrienortho
blog.com). A blog is a defined as a discussion or
informational site published on the World Wide
Web. It consists of discrete posts. Most blogs are
the work of one individual, however, recently
multi author blogs have been developed and the
posts contained therein are written by a large
number of authors. Most blogs are interactive
and allow the readers to leave comments on each
posting. This feature allows for real time con-
versation. There are several blogging platforms
that are available at no cost, for example,
Wordpress and Blogger. The blog can be hosted
by these organizations at no cost or the blogger
can pay for hosting on any web hosting company
(approximately $100.00 per year). The advantage
of this is that the blogger has complete ownership
and control of the content.
How did I start?
In November 2013, I had some free time and
decided that it might be a good idea to start
writing a blog. I started by researching blogging
on the Internet and came across a couple of
books that I subsequently downloaded. These
gave me very basic instructions and “walk-
throughs” on how to set up a blog. They took me
through the stages of selecting my blog software,
deciding on a blog name, registering it and then
putting it on the internet via a hosting company.
At the end of my first day, I went from having
nothing to a blog that was up and running and
working very effectively. It was surprisingly easy.
My next step was to decide what to write about
and since I was attending the British Orthodontic
Conference in Manchester at the time, I thought
that I would write a review of each day. I pub-
lished the blog, publicized it on Twitter, and was
surprised to find that it was read about a 25 times.
I then expanded the posts to include descriptions
and commentaries on clinical research papers as
they were published by the Journals. As my
confidence grew I introduced posts in which I
made a personal comment or critique of ortho-
dontic developments, for example, methods of
reducing the length of orthodontic treatment.
Over the next 4 months the readership of the
blog grew to about 200 hits a week. Progress
continued with increasing numbers of visitors to
the site and in March 2014, I was attracting 4000
hits per month. In April 2015, I decided to
publicize the blog on Facebook and this resulted
in a marked increase in readers and hits went up
to 9000 per month by May and this number has
slowly increased to 12,000 hits per month in
January of this year. Readership is still increasing
by about 1000 hits per month. My interpretation
of these numbers is that given the community in
which we practice in, I believe that the blog is
surprisingly successful.
I would be happy to provide readers of this
article with information on setting up your own
site. All you need do is contact me. None of this is
particularly new or difficult and this is really
based on my personal experiences.
Do some research
It is very easy to waste a large amount of time on
making mistakes, particularly with software and
hosting. So, you need to spend some time
researching the best way to move forward. I did
this by buying two excellent books that I found
from among the many out there to choose from.
In effect, they walked me through the process of
 Orthodontic research
setting up. These were very basic and take you
through it step by step.
Get good software and hosting
There is a large amount of free blogging software
and hosting. However, this can be rather basic,
and you need to be careful what you use. Another
important decision is whether you will use
Wordpress or another platform. I decided on
Wordpress because it the most popular blogging
software and the support is good. Wordpress
comes with many templates to which you simply
add your content. I started with one of these but
then I bought a more sophisticated theme from a
development company. This was not expensive
and it gave the blog a more unique appearance. I
also decided to pay for hosting because I wanted
a degree of independence.
Write good posts
This may be obvious but you need to write
something that people want to read. Again, there
are many books and websites from which to
obtain information on how to write a blog post.
In short, I would advise you to write in simple
non-technical language, try not to make your
posts very formal, and use nice illustrations to
make the posts more interesting. Remember,
people will read your posts on phones and other
mobile devices, so they do not want to read long
complex posts. You should aim to write some-
thing between 500 and 1000 words at the most.
You can also make the posts more interesting and
understandable by inserting tables and other
graphics.
When I initially started, I concentrated on
providing information on recently published
research articles and then started posting my views
on more controversial areas of orthodontics. I also
posted several posts that I thought would be
humorous. Ironically, one of these on “24 month
braces” is the most popular post on the blog and
has been read over 10,000 times. My advice is to try
and provide a mixture of content that would
appeal to the type of readers that you hope to
attract.
Publicize the blog
This sounds obvious, but you cannot rely on
simply writing good posts. With any blogging
113
software you can set it up so that when you
publish a post the title of the post and the content
is circulated by other social media. I do this by
linking my posts to Twitter, Linkdin, Googleþ,
and my Facebook page. However, if this is going
to be effective then you need to work on making
sure that you are connected to many people
through these platforms. As a result, it is neces-
sary to work on building a following of people
who are interested in what you have to share. I
found that the best way of achieving this was to
place an e-mail sign up form on my site. This
gives people an option of subscribing to the blog,
so that when I published a post they got an e-mail
letting them know of its existence. It is very
important to allow people to take their own
decision to subscribe. It is not good practice to
simply add all your contacts to the blog e-mail list.
I am sure that people do not want to add to the
large amount of junk mail that we all get.
Other platforms
There are, of course, many other platforms, for
example, Facebook, Googleþ, and LinkedIn. I
do use these for highlighting when a post is
published and I also post the details of papers
that I am going to discuss in the near future.
However, I am not a great user of these in any of
the other ways that they are used. I guess that I
am too old now and it takes enough time to work
on the blog.
Words of caution
If you start using social media it is also wise to be
very cautious. We are all aware of celebrities and
politicians who have made mistakes with inap-
propriate use of social media. This is particularly
important for us as health care providers who
supposedly operate within and conform to a set
of professional ethics. Most of our regulatory
bodies have policies on the use of social media
and it is essential that you follow these. Penalties
can be severe and it may be possible to lose your
license to practice. The three most important
caveats are that you should not post any infor-
mation on patients without their consent; you
should not make derogatory comments about
patients, other practitioners, particular vendors
and their products or services; and finally, you
114 O’Brien
should not be posting any inappropriate or
offensive content.
Apart from these issues, the following are
several pieces of advice that I believe are relevant
and important. First, you should read everything
that you intend to post on any media very
carefully—several times. If possible, leave several
hours before posting and read it again. As a
general rule, do not post any content when you
are tired; nor should you respond to messages
late at night or when you cannot give required
responses your full attention. I have learned from
my mistakes in this area, when I have responded
to comments on some of my posts, without being
sufficiently careful or polite with my responses.
These have caused problems that took some time
to resolve. One solution is to imagine that you are
talking to someone in a very public venue. This in
and of itself tends to make you more polite.
Communicating research findings to
patients and public
I only really have experience in communicating
research to other dentists and orthodontists, but
I have been made aware that several lay people
follow my blog. They have fed back to me that
they find it a very useful source of information
and I hope that one day I can publish lay versions
of my posts. Consider your patient base and
potential future patients. Is there specific infor-
mation that you want to expose them to. In this
way the use of social media to do so becomes a
very powerful marketing tool.
If you are going to do this on your blog or
website, it is very important that you make the
information understandable to people who are
not orthodontists or dentists. Do not over-
compensate and make it too simple. Soliciting
feedback will let you know whether the level you
are “speaking” at is appropriate. It is possible to
use electronic means that give you an indication
of the “readability” of your text and one of these
is built into Wordpress. One suggestion is to write
the post and then show it to a person who is not a
health care professional and ask them if the
understand it and ask them for suggestions on
how to make it more readable or understandable.
It is also important to make sure that any
claims that you make regarding the treatment
you render is supported by evidence. The regu-
lations on the content of websites vary from
country to country, but the important concept,
both from an ethical and legal perspective, is that
you should not mislead your patients. Doing so
may lead to administrative and civil exposure
from regulatory bodies and patients who can
show an “injury” due to the false or misleading
posted information found on your blog or
website.
The future
As we all know the internet is a rapidly changing
environment and I have no idea what forms of
communication and dissemination we will be
using in 5 years. But one important current issue
is open access to research information. Open
access means unrestricted on line access to
research publications. There are two main ways
that an author can provide open access. These
are by archiving their publications in an open
access repository, for example, a University
library. The other way is by publishing in an open
access journal. This latter method is provided by
the Angle Orthodontist, which to my knowledge
is the only open access orthodontic journal.
However, other journals do give access to some
articles.
The main driver behind open access is to
increase the dissemination of research findings.
Currently most journals restrict access to sub-
scribers, society members, or large educational
establishments. As a result, access to potentially
valuable research information is restricted. I am
sure that we have all experienced “hitting the
paywall” when we are searching for a particular
journal article. This is particularly ironic when
research is paid for by public funds; yet the results
are not available to the public who funded the
research.
The argument against open access is that
someone needs to pay for the cost of the Journals’
editorial process and editor, the peer review
mechanism and the publishing of articles.
Methods to overcome this have been made by
enabling authors to pay for the publication of
their paper, so that it can be open access.
However, this may only be possible if they hold
research funding or have other resources.
It is also interesting that while the open access
movement has grown, there are perhaps more
ambitious suggestions that authors can publish
their research articles on their own websites, blogs,
 Orthodontic research
or their University websites. This is possible now
for articles that have been refereed and it is
acceptable to publish a “pre-publication” version
of an article. However, it is also possible to publish
an article that has not been refereed on a website.
This means that readers will need to draw their
own conclusions on research reports by using
their research knowledge and training which in
many cases, if the readership is public based, may
be minimal to non- existent. Even if the reader-
ship is professionally based, self-publication may
be a viable means of distribution as there are many
cases wherein refereed articles have been found to
lack certain quality or validity. In summary, going
115
forward via self-publication may be a viable
method for dissemination but it is probably going
to be several years away as there are considerable
obstacles to progress.
The future is hard to predict but I suspect a
large amount of dissemination of research find-
ings and opinion will move to blogging platforms
and other forms of social media. There is a danger
of this being overwhelming for the clinician sci-
entist and we will need to improve our skills in
interpreting research and become selective in our
reading. The future of research dissemination is
completely unknown but for some of us it is
exciting and fraught with positive possibilities.
How to talk to patients when things go
wrong
Elizabeth Franklin

Orthodontists love to create beautiful smiles. You all work hard to formulate
effective treatment plans, and treat your patients with diligence and care,
working toward a successful outcome. When things go smoothly, your job is
easy and satisfying. Life is good! You can go home and sleep soundly. But,
what happens when things do not go as completely planned? Suppose your
treatment plan is not achieving the result that you expected; or that the
treatment itself is not progressing satisfactorily. It could be that the patient is
not cooperating in the manner they need to; or, it could just be that
physiology is working against you. When these instances occur, and they do,
the lack of progressed is experienced by not only you, but by your patient as
well; and it is this lack of progress may be causing the doctor/patient
relationship to deteriorate. Now, how do you feel? Are you stressed during
the work day? Do you carry that stress home at night? Many doctors have
reported difficulty sleeping when they encounter patient and/or treatment
problems. While these scenarios have kept some doctors awake at nights,
others have reported that they feel like they have chosen the wrong career.
Almost every job has some type of problems associated with it. Every
interpersonal interaction is subject to misinterpretations and misunder-
standings. You spent many years choosing the career path you did, do not
doubt your career choice. However, it is possible that you may not be
managing the occasional big issues or even the smaller day to day problems
well. This is a skill you can learn. How? By learning to communicate with
people and manage these problems so that they do not consume you nor
take up more space in your mind and heart than is appropriate. The following
are a few examples of problems that orthodontists have frequently reported
to the claims department and they are accompanied by exemplars of how
good communications can play a role in alleviating these adverse occur-
rences. (Semin Orthod 2016; 22:116–120.) & 2016 Published by Elsevier Inc.

Case 1 This is a difficult situation. This teenage girl and

Y
ou have been treating a 14-year-old female for
1 year. You are waiting for the maxillary canines
to erupt. You take a panoramic x-ray and realize
there is a problem. The canines were impacted and
they now have moved directly into the roots of the
lateral incisors. You estimate there is approximately
30% root resorption of the lateral incisors. How do
you tell the patient and her parents?
AAOIC, 401 North Lindbergh Blvd, St. Louis, MO 63141.
Address correspondence to Elizabeth Franklin, AAOIC,
401 North Lindbergh Blvd, St. Louis, MO 63141. E-mail:
liz@leclairinc.net
& 2016 Published by Elsevier Inc.
1073-8746/16/1801-$30.00/0
http://dx.doi.org/10.1053/j.sodo.2016.04.007
her parents will be upset at the long-term prognosis
that includes the possible loss of the lateral incisors,
both from a functional and esthetic standpoint. Root
resorption is an esoteric problem that can occur with
or without orthodontic treatment, but when it
occurs during treatment, the blame is usually placed
on the practitioner who provided and monitored
the treatment. Informed consent should have been
discussed and obtained at the beginning of every
patient’s treatment. The possibility of root resorp-
tion must be listed in all effective Informed Consent
documents. If you covered this potential negative
consequence before treatment began, should it
ultimately manifest itself, this discussion with the
patient and her parents will not be unfamiliar to the
family and should be less difficult for all concerned.

Seminars in Orthodontics, Vol 22, No 2, 2016: pp 116–120 116

 How to talk to patients
Handling
If you are upset at what has occurred, imagine
how they will feel when you have to break the
news so the first thing to do is to calm down.
Understand as much as you can about what has
occurred and why and make a realistic deter-
mination as to what you believe the con-
sequences will be. Arrange an appointment
with the patient and her parents for a face-to-
face meeting. Present the facts/details—show
x-rays. Explain the problem, its cause, its pro-
gression, and tell them what you will do to
manage it going forward. If the root resorption
is not severe, assure them that as you continue
treatment, you will take extra care that the
lateral incisors are protected as much as
possible from any additional resorption. There
is a good deal of support in the literature for
the fact that unless roots are resorbed sig-
nificantly, the likelihood of tooth loss is mini-
mal. Assure them that the teeth will not be lost
if that is the case. Explain about resting phases
and the possibility that both treatment
mechanics and treatment goals may have to
alter slightly.
If the root resorption is significant and you
know the lateral incisors will be lost, talk to them
about possible restorative options. The family will
be concerned not only about their daughter’s
future esthetic and functional issues, but also
about restorative costs they might incur. Do not
make promises to pay for the future treatment.
The case must be reported to your professional
liability carrier for appropriate investigation. It is
appropriate, however, to acknowledge the fam-
ily’s concerns and to support them in finding
solutions.
Take note
Tell the family as soon as possible after discov-
ering any problem. Never be the second doctor
to give a patient bad news. In many professional
liability claims, the patient learns about root
resorption from the general dentist, not the
orthodontist. When that happens, the family and
the general dentist assume the orthodontist not
only caused the problem, but failed to apprise
them or attempted to cover it up. If this happens,
the trust between orthodontist/patient/parents
is often irrevocably damaged.
117
Case 2
The scenario is similar. You have been treating a
12-year-old boy who presented to you with sig-
nificant crowding in both arches resulting in
your decision to extract all four first bicuspids. At
some point mid treatment you come to the
realization that the extraction spaces are not
closing as you had expected. You take a progress
panoramic x-ray and see severe root resorption
developing on all 4 maxillary anterior teeth. You
realize that the treatment must stop immediately
to prevent further damage and possible loss of
teeth. You will not be able to close spaces.
Handling
Again, first calm yourself down. Make a realistic
evaluation of the situation. Research the restor-
ative options that will be available to deal with the
remaining spacing. Again, set up a meeting with
the patient and his parents at the office and at a
time when you will be able to have a somewhat
prolonged conversation without being rushed to
see the next patient. Show them the x-rays and
explain the danger in continuing with active
treatment to attempt space closure. Advise them
that treatment must be terminated to prevent any
further resorption. Refer them to the doctor who
will be the restorative dentist. They are likely to
express concern about additional costs; do not
promise to pay the additional costs. Merely
indicate that this will be dealt with once a
definitive restorative plan has been developed.
This is a matter for the insurer to investigate and
handle.
Case 3
A 14-year-old male patient has been in treatment
for about 18 months during which time he has
consistently exhibited poor oral hygiene. You
were astute enough to document this on every
occasion and you frequently addressed this
problem with both him and his mother duly
noting all conversations in the patient’s chart.
You know you believe it is time to terminate this
child’s treatment before serious caries or decal-
cification occurs to his teeth. You foresee that the
patient probably needs about another year to
complete his treatment.
118 Franklin
Handing
Once again, it is important for you to be relaxed
and in control. Arrange a meeting with the
patient and his parents. Remind them of the
patient’s ongoing oral hygiene deficiencies and
your continued advisements regarding this. Also,
be frank about the potential negative con-
sequences associated with continuing ortho-
dontic treatment under conditions that
apparently are not going to change. Tell them
that treatment must end, to protect their child’s
dental health. If they argue, remain firm.
Remember, you are the orthodontist; you know
what negative consequences can occur if treat-
ment is continued in the face of poor oral
hygiene and it is your duty to educate the patient
and parent in this regard.
Case 4
You are beginning treatment on a young boy. It is
the type of case that you determine would benefit
from an atypical extraction pattern. You mis-
takenly write the extraction note for the first pre-
molars when you meant to have the second pre-
molars removed. The dentist or oral surgeon
follows your extraction order. You see that the
incorrect teeth were extracted as soon as the
patient returns to resume treatment.
Handling
Tell the parents of the discrepancy immediately. If
you believe you can close the spaces orthodon-
tically with no problem, or with minor impact on
the ultimate outcome, explain what you will do.
Do not assume that there will be no con-
sequences as a result of the error and therefore
you can attempt to withhold the mistake from the
family. If down the road, you are unable to
achieve a satisfactory result, when you ultimately
disclose the mistake months later, it will only
anger the parents causing not only a loss of trust
but intense negative feelings due to the
attempted deception. The AAOIC claims
department handled a case based on these facts.
The primary impetus behind the ultimate lawsuit
was not so much the error but was grounded
more on the fact that the doctor had failed to
disclose the mistake.
Case 5
For 9 months you have been treating a young girl
for crowding on a non-extraction basis. At each
visit mom is demanding, loud, disruptive, and rude
to you and your staff. You and your staff are mis-
erable every time the child has an appointment.
Handling
This situation happens more frequently than
practitioners think and can happen for a host of
reasons. The bottom line is that if the relation-
ship between the doctor and parent/patient has
deteriorated to the point that the parent/patient
is hostile, it is totally appropriate to consider
terminating the child’s treatment. No doctor can
or should work under intolerable and abusive
conditions as doing so not only creates a poor
working environment but the presence of this
type of behavior can easily affect one’s pro-
fessional judgment and negatively impact on the
quality of care rendered.
Occasionally an orthodontist will report that
the parent/patient is abusing to the staff. It is
your responsibility as the doctor to protect your
staff from inappropriate behavior by either a
patient or a parent. Not to do so is tantamount to
allowing an adverse working environment to
exist. In such situations, early termination of
treatment is appropriate. Explain that a good
doctor/patient relationship is critical to a suc-
cessful outcome, that the relationship has obvi-
ously deteriorated, the patient/parent has
apparently lost trust in the orthodontist/office
and that you have decided that the treatment will
no longer be continued in your office. Offer to
remove appliances if appropriate, and if such was
the case, to provide a retainer to preserve the
progress to date. Make sure to send an early
termination letter, (an example of one can be
found in another article in this issue) and advise
the family how to locate a new orthodontist.
Case 6
A 60-year-old adult female patient, a professional
woman, presented for treatment with minor
upper and moderate lower crowding. She wanted
limited treatment which was successful. A short
time after her braces were removed, about 6
months into retention, she reported that her
 How to talk to patients 119

lower incisors had relapsed to some degree. She Listen and empathize
wanted her teeth moved back into alignment.
When there is a problem and bad news to convey,
Although her retreatment was going well; the
first consider the issue carefully. Attempt to
orthodontist felt he should stop as soon as pos-
discover what went wrong and why. Performing
sible because he perceived that the patient was
your own mini root cause analysis can help you
developing some periodontal issues. The patient
both better understand the problem at hand and
assured the orthodontist that she was periodon-
benefit you in terms of developing protocols for
tically sound, her bones and gums were fine, and
your office to try to minimize similar future
she insisted that her treatment continue. At this
occurrences. Next, you must anticipate how you
point, the patient’s demeanor was becoming
believe the patient will take the news. Put yourself
demanding and aggressive. Treatment continued
in the patient’s or parent’s place in an attempt to
until periodontal issues ultimately became to be a
understand what they might be hearing and
significant problem. The patient sued the
feeling? For example, if you tell mom that her
orthodontist. How do you convey to a middle
teenage son has developed caries and decal-
aged high powered professional woman with
cification due to the poor oral hygiene which you
exceptionally high expectations for the outcome
continually reported to both of them, mom may
of her treatment, that she must forgo her
have a myriad of feelings; among those are: (1)
anticipation of perfect teeth/smile in order to
she may feel guilt because she was unable to
preserve her oral health?
change her child’s behavior, (2) she may feel that
you are criticizing her parenting skills—even if
Handling you are not, and (3) she may feel financial fears
because she will be faced with large restoration
Explain the periodontal concerns/issues to the
charges.
patient. Refer her to a periodontist immediately.
The better you can empathize and understand
At this point you need to communicate with the
the underlying factors in her situation, and from
specialist. If it appears to you and the perio-
her perspective, the better the message will be
dontist that orthodontic treatment should not
relayed. Can you assure her that you understand
continue, advise the patient. Explain that the
her frustration with the situation and that you
important issue is to prevent any further damage
recognize she attempted to manage the prob-
to her teeth and gums. If restorations will be
lem? Can you acknowledge the negative con-
necessary, refer her to a prosthodontist, or
sequences she is facing? Can you suggest
general dentist who can provide the best care.
alternatives that may make handling the problem
Recognize her critical needs—to look good when
easier and less overwhelming to her? Many of the
dealing with the public while maintaining max-
communication breakdowns that we find in
imum dental health. If the patient does not
claims actually developed as a result of the bad
consent to terminating the treatment, advise that
news having been conveyed thoughtlessly, with-
you will not continue and that she will need to
out regard to the other person’s feelings and
seek treatment elsewhere. The patient may allege
without acknowledgment of his or her situation.
practice below the standard of care, but if so, any
Most people do not need their problems fixed as
damages suffered will be less than if treatment
much as they need them acknowledged.
were to be continued, her periodontal disease
progresses, and tooth loss occurs.
All of these scenarios carry a similar message;
Are you afraid of conflict?
that being once you know there is a treatment or
patient issue or situation with which to deal, how Are you uncomfortable conveying bad news? Do
should you handle it? Do you react quickly, what you must to get over it. You cannot expect
aggressively, defensively; or, do you apologize that in a career involving intense personal serv-
and make promises, even if you do not believe ice, that at some point in time you will not have to
you are to blame? Do you send your office give someone bad news. Do not delegate the task
manager to handle problems because you do not to a staff person; you are the doctor. It is your
like conflict? None of these approaches is par- patient and your responsibility. Decide what you
ticularly fruitful. need to say and do, then say it and do it—with
120 Franklin

confidence and firmness. If the cause of the Be detailed and thorough in your
problem was not yours, state that, but be sup- treatment planning and case handling
portive in assisting the patient to find a solution.
Take good initial records including photos,
There may not be one that suits the patient, but
cephs, models, and beginning, progress, and
your job is to do all you can under the circum-
ending radiographs. Obtain a thorough health
stances. Do not be so frightened and apologetic
history. Read and review all records carefully and
that the patient or parents feel they can
regularly. Always have an informed consent dis-
manipulate you into giving them free dental
cussion and have a form signed to document it. If
treatment for themselves, for others, providing
there are multiple treatment options, discuss
refunds or paying for future required care. If you
each one with the patient, and document the
need an assertiveness course to manage this, do
chosen one. Completing all of these details will
yourself a favor and take one.
minimize the potential for problems. They will
If the bad news is clearly due to your own fault,
also often provide the necessary support if you
do not beat yourself up. Again, in the fields dealing
need to give the patient bad news. Remember,
with providing personal services, it happens. No
effective communication is the key. Silence and
one is perfect and errors in judgment, technique,
avoidance are not appropriate. While in some
diagnosis and the like happen. Call your pro-
circumstances, silence is indeed golden, in the
fessional liability carrier to report the claim. The
arena of professional practice it is merely pyrite
insurer will assist you in handling all of the details
having little if any value.
going forward. The insurer, who in reality is an
agent for you, will investigate the claim, determine
and recommend an appropriate resolution.
Stylistic communication and the second
opinion
Laurance Jerrold, DDS, JD

One's style of communicating is vitally important to both the message being

sent as well as to the message being received. We have often heard that how
something is said is far more important than what actually was said. With
this in mind, this piece deals with the essence of stylistic communication and
this type of communication in proffering a second opinion. There are many
reasons that people seek second opinions just as there are many reasons why
doctors offer them. These reasons will be discussed in detail. This article will
go into a detailed protocol for how to offer a second opinion. There are 3
types of second opinions that will be discussed. The first is the pre-treatment
consultation. The second is the mid-treatment second opinion. The final one
is the second opinion offered when one is acting as an expert witness. The
offering of a second opinion is an art that needs to be studied and when
expressed is truly a communications masterpiece. (Semin Orthod 2016;
22:121–126.) & 2016 Elsevier Inc. All rights reserved.

A new patient has scheduled an initial

appointment. It is for a second opinion.
Maybe you know that, maybe you do not. What you
say to this patient and how you say it may either
smooth over some rough surfaces or create sig-
nificant potholes for the first practitioner
depending upon your communication skills. How
you communicate may also decide whether the
patient stays with you or goes somewhere else. This
article will attempt to punctuate the importance of
stylistic communication and its consequences.
Stylistic communication is conceptual by
nature and attempts to establish principles capa-
ble of explaining the array of choices made by
individuals or groups through the language they
use, such as dialects and registers. It can also be
applied to areas such as discourse analysis. Some
common features this style of communication
include is the use ideolects or individual dialects,
particular uses of grammar, attention to the use of
passive and active voice, the length of sentence
structure, language register, and so on. It also
takes into account the connections between the
NYU-Lutheran Medical Center, Brookly, NY.
Address correspondence to Laurance Jerrold, DDS, JD, 180
Riverside Blvd—Apt 25B, New York, NY 10069. E-mail: drlarry
jerrold@gmail.com
& 2016 Elsevier Inc. All rights reserved.
1073-8746/16/1801-$30.00/0
http://dx.doi.org/10.1053/j.sodo.2016.04.008
form and effect of the language used. Another way
of looking at it is to view what is going on within
the language as it is being used. It is, in my
interpretation, a means of making the language
your own, unique to yourself, a reflection of who
you are, and how you present yourself to others
through a combination of verbal, tonal, and body
language. It is a morphing of communicative
subtleties into a powerful interactive tool.
The first commandment in communication is to
try to determine what the other party wants to hear.
Thus in the second opinion arena, there is no
better first question than finding out if a new
patient is there for an initial consultation or a
second opinion. When the new patient calls the
office to make the initial appointment, one of the
questions posited by your front desk staff should be
“Is this appointment for a second opinion?” If the
patient asks why, tell them why. If the patient does
not ask why, take the opportunity to tell them why
they would want to know. Either way, every new
patient should know that by the end of the con-
versation, the doctor provides a good number of
second opinions. This in and of itself creates an
aura of “when you need to know what is really
going on, this is the person that everyone goes to.”
Why do people seek second opinions? It may be
because patients want to be sure that the first
doctor is correct in his diagnosis and treat-
ment plan. Occasionally, a neighbor, friend, or
co-worker will tell a prospective patient that they

Seminars in Orthodontics, Vol 22, No 2, 2016: pp 121–126 121

122 Jerrold
never heard of such a thing as was proposed by
this patient’s first doctor and that they need to get
a second opinion. Some people always get second
opinions when contemplating significant medical
care or a significant outlay of money for medical
treatment. Regardless, you want them to be
exposed to and to be able to compare the value of
services to be rendered by your office against all
other offices. They will think of it as comparing
price but you are communicating the value they
will receive for the services you will be both ren-
dering and proposing. Your office will also inform
them that you provide second opinions about
patients to other doctors who call on you for your
expertise. You want to impart the feeling that you
often provide this service and you welcome the
opportunity to do so again. You are the second
opinion expert; the “go to” guy or gal who rou-
tinely provides this valuable service. Inform the
patient that if they happen to have any records
from the first doctor to bring them along.
Should you charge for the second opinion?
The answer is a resounding “it depends.” If your
office provides free initial examinations, then
second opinions should also be free. If you
charge a fee for your initial consultation then
you should charge that same fee for a second
opinion. You need to be consistent in your
messaging regarding fees. The patient should be
told of any charges they might be responsible for
prior to coming in to the office. Above all, you
want to be perceived as being above board.
Should the patient be communicating what
the first doctor said? The answer is absolutely not.
You should discourage this type of communica-
tion. When a patient is seeking a second opinion,
what they are really hoping for, once money has
been taken out of the picture, is a corroboration
of what the first doctor said. Once they have
confirmation of the first opinion or recom-
mendation, they now have assurance. Now they
can pick and choose among providers based on
other subjective factors that are important to
them. This is what they were seeking.
The only way you can honestly opine about
anything is if you do not know what it is you will
be agreeing with or dissenting to. For you to
know what the first doctor said may be helpful to
you, it may make it easier to sell the case for any
number of reasons, but it is certainly not helpful
to the patient who is seeking out an unfettered
and unbiased second opinion about a health care
concern. If the patient starts to tell you what the
first doctor said, STOP THEM! Tell them that the
only way you can provide an honest and unbiased
second opinion is to not know what the other
doctor said. You will immediately earn their trust.
Tell them that you will be glad to discuss any
differences between the two opinions after you
have completed your examination, your evalua-
tion of whatever records you have, and after you
have rendered your opinion. Tell them that if
there are differences that you will attempt to
explain them to the patient based on the science
and the art of your profession. After presenting
yourself in this manner, to paraphrase Renee
Zellweger in the film Jerry Maguire, “you had
them at hello.”
One of the many art of communication is to
present yourself in a certain fashion. You want to
come across as the most open and honest
practitioner they have ever come across and the
way you communicate that is to convey the aura
that you have no ax to grind regarding the
previous doctor, no dog in the fight, and no stake
in the outcome. Subconsciously, they have to
believe that that your opinion is just that, it is your
honest and unbiased opinion regardless of what
anyone else has said. You are not going to
besmirch or belittle the first doctor; you are not
going to come off as haughty or arrogant; you are
not going to communicate anything other than
you are here to serve the patient’s needs. What
they are seeking is advice to assuage their con-
cerns and to answer their questions, and that is
precisely what you plan on delivering.
You need to develop a protocol for perform-
ing second opinions. The US Forest Service has a
structured briefing protocol to give direction to
firefighters. It has direct applicability to ortho-
dontics. Its acronym is STICC and stands for
Situation Task Intent Concern Calibrate. Let us
look at these one at a time.
The first is Situation. This is how the patient
presents. Essentially you are making a diagnosis
of what the orthodontic problem or concern is.
You do this not just for your sake, so you can get
your thinking in order, but also so that you can
effectively communicate the situation to the
patient. Here is what I see. Here is what I think
you face. Here are the clinical problems we have
to deal with. This has to be done in a manner
so that the patient clearly understands their
Situation.
 Stylistic communication
The second is Task. This is where you com-
municate, here is what I think we should do; here
is what you need, here are the different ways to
address your concerns or problems. You should
utilize models, pictures, and YouTube postings;
whatever will help them accept the proposition
that you know exactly what has to be done
and how.
Next comes Intent. This is the “here’s why”
portion of the verbal discourse. These are the
reasons why whatever condition(s) the patient
presents with require or can benefit from treat-
ment. This is where you get to do your thing, your
sales pitch, your shtick. This is where you get to
show just who you are. This is the superhighway
of interpersonal communications, up close and
personal as they say. Be clear, concise, knowl-
edgeable, and be professional. You win it or lose
it right here.
We follow this with Concern. This is where
you need to convey that you care about the
patient. You know that there are certain risks,
you know that not every case turns out to be a
home run, you know the compromises and
limitations that attach to the plan you are
communicating. You must explain this to them.
Now, here is the hook, you will protect them.
You will keep an eye out for these things, you will
monitor the progress closely, you are there to
protect them from themselves and the array of
ghastly boogeymen that haunt and stalk all
orthodontic cases.
Finally, we Calibrate. We insure that we are all
on the same page. We ensure that they actually
understand what we have said and if they did not,
what is it they did not get; and then you find
another way to explain it to them. You will do all
of this at their level of comprehension, using
their primary language, not Dentalese. Ask if they
have any questions. Make sure you have answered
them and do a quick circle around and tie it back
in to their chief complaint.
After STICC is completed, it is the time when you
get to ask “what did the first doctor tell you?” You get
to reconcile the differences and explain the nuan-
ces; to tell and show them that you are aware of
differences in perception regarding diagnostics and
differences in preferences regarding mechano-
therapy. You should do all of this in a language that
neither denigrate the first doctor or the profession
nor any vendor because of the differences in
hardware that any practitioner chooses to use.
123
Finally, hit the patient with the price. You may
be higher, you may be lower, but this is your fee.
What they are about to buy is not orthodontic
treatment. What they are about to buy is your
service; your knowledge of their needs; your
ability to provide what they are seeking; and your
ability and desire to care for them throughout
the treatment process. This is the value you are
selling. By this time, if you have communicated
correctly, your message has been conveyed.
Assuming you agree with what the first doctor
said, this is where you get to take the high road.
You tell them that you would love to treat them
but this is a decision they have to make as you and
Dr. First agree on virtually everything and either
way they are in good hands. You tell them if they
have any questions or concerns moving forward
you are there and they should feel free to contact
you at any time. If on the other hand you disagree
with Dr. First, tell them again that you under-
stand why he said what he said but this is how you
see it and you welcome the opportunity to discuss
the matter again if they feel a need to after they
have thought things over. You always leave the
door open for them to return for a follow-up
consultation.
What we have discussed so far is the pre-
treatment second opinion however the more
vexing situation is often the mid treatment sec-
ond opinion. This situation is most often enco-
untered when the patient has been in treatment
for any given length of time and presents to your
office; again, seeking confirmation. The differ-
ence is that this time they have the suspicion that
something is not right. Either things do not look
right, the bite does not feel right, the treatment is
taking too long, spaces are either opening or
closing, they have completed paying but treat-
ment is not yet completed, and so on. In this
situation, patients are also looking for consensus
or confirmation about their feelings however
they are also scared and concerned. Scared
because treatment is not working out or is taking
too long; and concerned because now they are
faced with the possibility of having to change
horses in midstream. What are they going to do?
Is it going to cost more, and if so how much, and
who should be responsible for paying for it? How
much longer will it take and how involved will the
process be?
This should not be a problem because as we
know, you are the go to guy; you are Mr. second
124
opinion. You do this all the time. When the
patient called your office for an appointment,
once again you asked, you always ask, is this for a
second opinion; assuming of course that the
patient did not indicate that this was the reason
that they called you for an appointment.
Let us first address the 800 pound gorilla in
the room. Do you have to call the first doctor to
get his permission to see the patient, to inform
him of what is going on or to get background
information from him concerning the treatment
of the case to date? The answer is NO! First,
patients are autonomous beings and have a right
to a second opinion any time they choose to seek
one out. Second, patients may very well return to
the first doctor after obtaining the second
opinion based on what was said and how the
message was delivered. They may not want the
first doctor to know they are getting a second
opinion as they may not want that Doctor, to feel
as if they do not trust him (they do not or they
would not be getting the second opinion but they
have not committed to not returning to him if it
turns out that the second opinion verifies that
everything is okay). If the first doctor finds out
they are “questioning his treatment” the doctor–
patient relationship may be irretrievably dam-
aged, as the professional ego once bruised does
not heal easily. Finally, you are not your brother’s
keeper and you have no obligation to protect
him. Remember, the second opinion must be a
totally honest unbiased opinion. If you speak with
the doctor and if he bad mouths or blames the
patient you may very well be influenced which in
and of itself has the potential to compromise the
openness and integrity of the second opinion
process. Professional collegiality comes in later.
Ideally, the patient should present with an
initial set of records. It is very difficult to know
how far along you are on a journey if you do not
know where you started from. As we all have fairly
similar projected end points, we know the des-
tination therefore it is not tough to figure out
exactly where the patient is. However, as we
stated, the patient may be reluctant to let the first
doctor know they are seeking the second opin-
ion; thus there are no initial records. At this point
one is often tempted to call the first doctor to
find out where the patient started but be strong;
resist temptation. We have already discussed why
this might compromise the evenhandedness of
the second opinion process. The tack to be taken
Jerrold
should be that the first doctor mailed you the
records but the FedEx plane crashed; and when
you called to speak with the first doctor his office
manager states that he died yesterday of a heart
attack. Guess what, you now have to do the
second opinion based merely on the history
elicited from the patient in accordance to what
you see clinically and reasonably believed to have
transpired.
When the patient presents you should do two
things. The first is to go through STICC and the
second is to state and repeat the “second opinion
mantra.” Again, the first is situation. Ascertain
the patient’s status along the treatment time line
both from a clinical and temporal perspective.
Make believe that there are no braces on the
teeth. The dentition the patient came in with and
the position that the teeth are in is the result of
how the patient was born and subsequently
developed. What is the current orthodontic
problem? Now go back and factor in the notion
of prior treatment that has resulted in the patient
being in the position they are in. Essentially, you
are making a diagnosis of what the orthodontic
problem or concern was originally and is now at
its present stage or phase of treatment. Once
again, you tell the patient here is what I see. Here
are the clinical problems, concerns, or hurdles
we have to deal with. If you can, indicate what you
believe to be normal or abnormal given the
totality of the circumstances as you see them.
Remember too that this has to be done in such a
manner so that the patient clearly understands
their situation.
The second prong is Task. Again, being purely
clinical and nonjudgmental, indicate what you
propose to do to get from where the patient is to
the destination of where the patient wants to be.
It is at this point that if you believe the patient’s
goals are unrealistic, you need to educate them as
to what is reasonable and attainable and what is
not. You are the teacher, you are the guide, and
you will lead them down an appropriate path.
Here is where you get to mollify some of their
concerns. As previously stated, use whatever
props you need for educational purposes. All of
this is done in an even modulated tone reflecting
no disconcertedness with what has already
transpired.
Tine number three is Intent. Again, explain
why you are proposing whatever it is you are
proposing. You must believe there are certain
 Stylistic communication
benefits to your proffered approach so saddle up
and ride them. Again this is the “here’s why”
spiel. Once again be clear, concise, knowledge-
able, and professional.
Next to last is Concern. Showing concern and
empathy for the patient’s situation is critically
important in this type of second opinion. It is
vitally important that the patient is reassured that
everything will be fine going forward. Whatever
problems there are, whatever compromises and
limitations exist, if there are any, are well within
your wheelhouse and will be dealt with to the best
of your abilities as you execute the plan already
laid out. If there are none and everything is as it
should be than reinforce that. Dr. First is appa-
rently dealing with all you have noted in an
appropriate manner and they should be secure
in their decision to return to him.
Last comes Calibration. We want to make sure
that you and the patient are on the same page
once again, that there exists a true meeting of the
minds. The critical point to remember and to
transmit to the patient is that orthodontics is a
soft science and as such there are differences
diagnostically, differences in mechanotherapy,
differences in goals and acceptable outcomes
and unfortunately, differences in the degree of
paternalism and professional demeanor exhib-
ited by different practitioners. Patients need to
be told that normal is a range and not a point.
That someone treated this patient differently
than you would have is quite inconsequential.
The point is to decide if the treatment to date is
one of many viable alternatives to get the patient
into the ballpark; not necessarily on any partic-
ular base. Patients can understand and accept
this if it is explained to them in a clear, rational,
and unbiased manner all the while providing
them with the empathy they need to trust the
message you are delivering. Finally, ask if they
have any questions and make sure to answer
them in a straightforward manner.
You are both a private and a public fiduciary.
Private in the sense that you owe this patient a
degree of honesty and forthrightness in your
obligation to apprise them of their status and
their prognosis. Public in the sense that you have
an obligation to uphold the integrity and repu-
tation of your profession without resorting to
denigration and one-upmanship of your pro-
fessional colleagues. It is this last part that we
need to address next.
125
The “second opinion mantra” is a simple
straightforward means of responding to patients
who are angry, distrustful, looking to lay blame,
and come to you seeking ammunition to use
against a fellow practitioner. They present in the
form of seeking a second opinion, however the
real reason is that they are on shopping spree for
whatever information you impart that will ulti-
mately be used against the first doctor. Your job is
neither to protect your colleague nor to help
punish him. Your job is to respond to your
patient in an open honest and forthright man-
ner. The second part can be done without
compromising the first.
The mantra goes like this. “This is what I see.
This is what I want to do. This is how long it will
take. This is what it will cost.” When the patient
responds “Why did he do it this way?” Your
response should be “This is what I see. This is
what I want to do. This is how long it will take.
This is what it will cost.” When the patient says
“Well he said it would take…”; your response
should be “This is what I see. This is what I want
to do. This is how long it will take. This is what it
will cost.” We could go on and on but you get the
picture. The point is you want to keep steering
back to true North, via clinical unbiased com-
mentary. You do not know why Dr. First decided
to do whatever it was he did. You were not
there, for the consultation. Your training is dif-
ferent than his; your philosophical approach to
diagnostics, mechanics, retention, and patient
management all are different. You have only one
very basic question to answer. It is—was his
diagnosis one of many that could be made; was
his treatment plan and biomechanical approach
one of many viable alternatives to address the
patient’s condition; was his management of the
case within acceptable parameters? Nothing has
to be as good or exact as you would do it, that is
an ego trip for one. Your job in the second
opinion arena is to let the patient know that what
was done to date is within acceptable parameters
or it is not. If it is not, state why; clinically, not
derogatorily. Repeat the mantra as often as
necessary, in a manner that fits the situation.
There is a third type of second opinion, which
of the expert witness. Assuming you choose to get
involved in the legal landscape, be it admin-
istrative (State Board activities), the civil milieu
(malpractice cases), or the criminal arena (yes on
occasion orthodontists engage in illegal activity)
126 Jerrold
it can be in one of the three ways. First, you can
be a party in a lawsuit, usually the defendant;
second, you can be a fact witness, usually a sub-
sequent treating practitioner testifying to what you
saw or what you did; or third, you can decide to
become an expert witness, a paid participant for
your testimony, for your opinion. The defendant
doctor’s testimony, his opinion will be first but
yours, the second opinion will follow. In this sit-
uation you are an advocate (yes, for either side)
and as an advocate, there will be some clinical
dissertation but there will be a good deal of
emotion also. Righteous indignation is often an
apt description. When testifying as an expert,
everything about you and what you say will be
scrutinized by the trier of fact; the jury. They will
not only listen and hang on every word (well you
hope they do) but they will evaluate your other
methods of oral communication including such
things as appearance and body language.
When you decide to communicate in this
environment you need to size up who the audi-
ence is in order to know how to speak to them
most effectively. You will get this information
from the attorney who hired you. The educa-
tional make-up, and the socio-demographics of
the jurors is critical in order to effectively com-
municate; for it will determine the level and style
through which you will pitch whatever it is you
are pitching. As in the case of the humble second
opinion given in the office setting it comes down
to the age old saw, it is not what you say but how
you say it.
I have written this piece in the manner in
which I speak. I have used grammar to punctuate
various pauses. I have used capitals and under-
lines to increase volume and importance. I have
used aphorisms and catchphrases often, as this is
how I try to get my listener to understand and
truly get what I am saying. I have tried to inject a
little levity into a dull but important aspect of
what we do. I have toned the language down at
times to promote seriousness. I have attempted
by writing through mimicry of my verbiage to
convey information via stylistic communication.
I hope I was successful.
Communications as an orthodontic risk
management tool
Laurance Jerrold

Communications are a vital part of the doctor patient relationship. In

orthodontic practice there are essentially 3 types of orthodontic communica-
tions: intra-office, inter-office, and extra-office. Various types of each commu-
nication will be discussed with sample letters for exemplary purposes. Utilizing
all 3 types can aid the practitioner in establishing a high risk management profile
and make daily practice easier, more meaningful, less stressful, and certainly
safer from a dent-legal perspective. (Semin Orthod 2016; 22:127–158.) & 2016
Elsevier Inc. All rights reserved.

O rthodontic practices utilize three types of

communiqués on a day-to-day basis—intra-
office, inter-office, and extra-office. Examples of
intra-office communications are all of the inter-
nal forms and documentation that effectuate
your day-to-day operations, policies, and proce-
dures such as your medical history form and your
informed consent form(s). Inter-office commu-
niqués entail all communications between you
and other medical personnel who are con-
currently caring for the patient such as referral
forms and synopsis letters that routinely go
between you and other health care professionals;
and insurance forms that emanate between you
and third party payers. Extra-office communi-
qués might entail such things as website content
or financial agreements given to the patient.
Obviously, many types of communications will
overlap categories because they serve dual
functions. Regardless of the category that these
communications fall into, they all serve at least
one common purpose, they serve as an ortho-
dontic risk management tool and all should be
utilized to the fullest extent possible.
When a new patient calls the office for an
initial evaluation, a succession of risk manage-
ment concerns is triggered. The best way to
evaluate these concerns and appreciate the role
NYU-Lutheran Medical Center, Brooklyn, NY.
Address correspondence to Laurance Jerrold, DDS, JD,
180 Riverside Blvd—Apt 25B, New York, NY 10069. E-mail:
drlarryjerrold@gmail.com
& 2016 Elsevier Inc. All rights reserved.
1073-8746/16/1801-$30.00/0
http://dx.doi.org/10.1053/j.sodo.2016.04.009
that intra-, inter-, and extra-office communica-
tions play in addressing them is to look at the
concerns along a time line. Let us start at the
beginning.
A general dentist informs a parent that her
daughter might need braces. He gives her the
name of an orthodontist or two in town and she
now does her parental due diligence, which
entails asking her coworkers, friends, and
neighbors if they have ever used an orthodontist
and if they know of any good ones. Lastly, mom
will do an internet search. Lo and behold one of
the names the general dentist recommended has
this great website. The site shows off the office,
extols the virtues of the Doctor, has a lot of
information about orthodontics, philosophy, the
various appliances used, testimonials from
patients (some real, some not) a map to get to
the office, various contact and informational
forms that can be downloaded and completed,
and so on.
One of the tabs on the home page directs mom
to a section that is brochure like in content and
which from a legal perspective can be viewed as
nothing more than an offer of one’s services
extended to the public for the sole purpose of
soliciting and inducing prospective patients to
accept the Doctor’s services based on the state-
ments made therein. In legal parlance, the state-
ments can be viewed as promises. If it can be found
that these photographs, statements, innuendo, etc.,
form a material basis on which the patient accepts
treatment, then it can also be argued that liability
may attach for breaching the expectations
expounded within the communication. Consider
the following statements, all of which were found in
various office brochures and mission statements

Seminars in Orthodontics, Vol 22, No 2, 2016: pp 127–158 127

128
collected over the years that arguably can be
claimed as false and misleading.
(1) Convenient flexible hours to suit your
needs.
(2) All insurance plans accepted for payment.
(3) Available for emergencies 24 hours a day,
7 days a week.
(4) Our treatment is quicker, less painful, and
carries less risk.
(5) Our state-of-the-art facility exceeds all gov-
ernmental rules and regulations regarding
sterilization.
(6) We promise to be prompt and respectful of
your time.
(7) We are dedicated to providing you with the
highest quality of orthodontics available
today.
(8) Your total dental health is our highest
concern.
(9) We will be in constant communication with
all of your other health care providers
during your treatment.
(10) With the advances in technology that
modern orthodontics has to offer, there is
no reason that an ideal result cannot be
achieved.
(11) It will take “x months” to correct your
child’s problem.
Keep these promises masquerading as
inducements in mind as we will refer to them
later on.
Another possible occurrence along the time
line and still in the pre-treatment context is to
consider the role that video imaging might plays
in creating a specific expectation on the part of
the patient. Many of us use proprietary software
that we purchase to help “educate” our future
patient. Videos of this ilk portray a certain mal-
occlusion and the role that a particular form of
mechanotherapy will have in correcting this and
shows a result that is akin to a promised
expectation all in the hope of inducing the
patient to accept the proffered therapeutic
intervention. Whether or not this form of
inducement regarding obtaining a specific result
can create a promise on which a patient has a
right to rely is obviously for a jury to decide;
however, if we are speaking of risk management
than perhaps we may want to limit the risk and
forego the video based on a particular
Jerrold
practitioner’s risk tolerance. Breaches of contract
of this sort if found to exist can subject the doctor
to liability for the value of the contract; in other
words, having to return the fee that the patient
paid you for specific results that were not
received as well as for any differences in fees
charged by the subsequent treating practitioner
whom the patient now hopes will be able to fulfill
those lost expectations.
Finally, in another commonly encountered
pre-treatment scenario, consider the promise
made by the office’s insurance coordinator that a
patient’s insurance will cover the cost of treat-
ment; a scenario most often encountered when
providing services for temporomandibular dys-
function secondary to a traumatic event resulting
in a whiplash sprain–strain type injury. If reim-
bursement is not forthcoming and the patient
can successfully claim that he or she was induced
to accept therapy based on this unfulfilled
expectation, it is easy to ascribe liability for the
breach of this promise to the doctor for the
unanticipated financial loss suffered by the
patient.
Breaking it down into legal elements, it could
be argued that the health care provider made a
statement, otherwise known as a promise, made
in some form of intra- or extra-office commu-
nication. The patient then relies on the state-
ment/promise and accepts treatment from the
doctor based on the expectation that the promise
(s) will be fulfilled. As a result of relying on the
given promise(s), the patient suffers damages.
The damages usually claimed are for additional
financial expense, and/or increased treatment
time resulting from having to go elsewhere to
correct the breached promises that induced the
patient to accept and undergo treatment with the
first doctor. While the doctor may be afforded a
chance to “cure” (correct) the breach, at this
point the doctor–patient relationship may have
been strained to the point where it is very
uncomfortable for one of the parties to continue,
given the personal service nature of orthodontic
therapy. Such is the nature of breach of promise
claims in the health care arena.
Another potential area of pre-patient contact
exposure may occur when medical history forms
are sent out (or filled out on line) prior to the
patient’s first visit to the office. Even if you review
this information before meeting the patient,
there have been a number of instances where the
Communications as an orthodontic risk management tool 129
130 Jerrold
lack of verbal communication between doctor
and patient has resulted in significant injury to
the patient because medical history information
was incorrectly transmitted via the form by a
patient who could not read, did not understand
the language used nor the questions asked. From
a risk management perspective, you should be
obtaining your medical histories verbally, face to
face. In this manner, you can never be found to
have treated a “stranger.”
In short, pre-treatment communications while
not high on the list of orthodontic risk man-
agement concerns has the potential to, and at
times has, exposed practitioners to liability. The
caveat is that if you are going to promise the
patient something, make sure that your promises
are yours and not generic statements purchased
from vendors and inserted into digital commu-
nication products. Ensure that they represent
assurances that you believe you are able to
deliver. Remember that in essence you are a
guarantor of the inducements used and your goal
is to ultimately meet or exceed the patient’s
expectations in regard to the communications
(the promises) you proffered.
Returning to our time line, our mom has
chosen her orthodontist—you. She calls the
office to set up an initial appointment. The first
communication that occurs from this point
moving forward is a note to thank the doctor for
referring the patient, or in the case where the GP
was not the referral source and to allow you to
notify him or her that the patient has been seen
by you. Either way, what you are doing is estab-
lishing that you are undertaking the creation of a
doctor–patient relationship. From a legal per-
spective, physicians do not owe patients any duty
to conform to a given standard of care unless a
doctor–patient relationship is in existence. By
using Form 1, you are confirming the existence
 Communications as an orthodontic risk management tool
or denial of that relationship as you are saying
that treatment is (1) recommended; (2) the
patient’s problem is best treated via recall
observation until a more opportune time to
initiate treatment arrives; or (3), that the patient
has decided not to take advantage, for whatever
reason, of the benefits of orthodontic treatment.
This type of form helps an orthodontist to
defend against a claim of misdiagnosis such as a
failure to recommend treatment when it was
indicated, or conversely, neglecting to treat if
treatment was indicated, when in reality it was
131
the patient who refused to accept therapy. This
scenario most commonly occurs in root
resorption cases involving maxillary lateral
incisors as a result of ectopically erupting
canines.
Once a treatment plan has been determined
and accepted by the patient, most offices send
out synopsis letters. Virtually every orthodontic
practice management software package contains
a type of this inter- and extra-office communi-
cation tool. Many offices send out two such let-
ters, one to the patient and one to the GP. The
132
synopsis letter is both a great practice manage-
ment and a risk management tool. A common
risk management problem comes about when
the synopsis letter to the patient paints a “sunny,
blue skies” kind of picture, while the letter to the
dentist depicts a “storm clouds on the horizon”
image. Imagine the following.
The synopsis sent to the patient notes that the
patient’s malocclusion is “ABC” and that with
good cooperation there is no reason not to
expect “XYZ” result. On the other hand, the
synopsis letter that is sent to the dentist, notes
that the patient’s “ABC” problem also carries with
it concerns about the patient’s periodontal
Jerrold
support, the potential for root resorption, the
need for permanent post-treatment stabilization,
etc. It is amazing how often the two letters seem
to be about two different patients; think Rem-
brandt verses Picasso. If the case is ultimately
litigated, it is difficult to reconcile the discrep-
ancies between the letters. Usually, the result is
that the patient claims that vital information was
withheld from them resulting in a claim for lack
of informed consent; an easily reached con-
clusion based on the orthodontist’s reluctance to
note any of the potential negative concerns in the
patient’s letter that were prominently mentioned
in the letter to the GP. The risk management
 Communications as an orthodontic risk management tool
caveat here is to ensure that everyone is on the
same page through your inter- and extra-office
communications.
Now that treatment is about to begin, there are
a number of inter-office forms letters that the
orthodontist needs to keep in his communications
arsenal. Besides being great risk management
tools, they have a strong practice management
component as well. The first one is a general letter
to the patient’s physician inquiring into whether
or not the patient has any medical conditions that
might impact undergoing orthodontic therapy in
any way. (Refer Form 2.)
While all of this information should have been
ascertainable from the patient’s medical history
form, it is a belt and suspenders type of risk
management posture that prudent practitioners
should adopt. In addition to its low cost and high
133
return value ratio, it carries the potential to
become another referral source as well, partic-
ularly if the patient’s primary care provider is a
pediatrician.
The next inter-office letter is specific to those
patients who present with a positive history of
cardiopathy that may require antibiotic prophy-
laxis for infective endocarditis. It asks the car-
diologist about the nature of the disease, whether
or not IE prophylaxis is recommended, and if so,
what regimen to follow. (Refer Form 3.) If you
send out this letter or make a phone call to elicit
the same information, make sure you get a
response. There are only a few things worse from
a risk management perspective than knowing
that you need to make a referral, making it, and
then ignoring the response or not following up
on not having received one.
134
The next inter-office communiqué goes to the
ENT physician, allergist, and/or pediatrician. It
alerts the medical specialist to your clinical and
radiographic findings; and inquires into whether
or not there is a history of, treatment for,
or recommendation regarding naso-respiratory
embarrassment, tonsils, adenoids, turbinates,
allergies, sleep apnea, etc.; and if there is, for the
specialist to treat appropriately and keep you in
the information loop. (Refer Form 4.)
Forms 2 through 4 should be used as often as
possible for the patient’s protection, your pro-
tection, as well as to keep your name in the
forefront of the local dental and or medical
Jerrold
community. One clinical problem area concerns
the use of “clearance letters.” These types of
communications, usually sent to a patient’s GP or
Periodontist, request evaluation of a patient’s
condition and a request to opine whether or not
the patient’s oral health status is compatible with
either the initiation or continuation of ortho-
dontic treatment. There are numerous instances
of doctors having requested clearance regarding
whatever the clinical issue of concern is only to
find that (1) a response was never received and
the doctor went ahead anyway, or worse, (2), a
response was received recommending “xyz”
treatment before initiating or continuing
Communications as an orthodontic risk management tool 135
136 Jerrold
orthodontic therapy but the recommendation
was ignored. (Refer Forms 5 and 6.)
The next pre-treatment type of communica-
tion is both intra- and extra-office and is one that
forms the basis for many orthodontic malpractice
suits. It documents obtaining the patient’s
informed consent. While an in depth discussion
of informed consent is outside the scope of this
article, it would be an error not to discuss the
communicative aspects concerning this legal
tenet. In essence, patients must be told in a
language they can comprehend such things as
what the problem is; how you propose to correct
it; what alternative methods exist for dealing with
the problem; the risks, limitations, and
compromises inherent in each approach; the
risks associated with foregoing treatment; the
opportunity to ask and have answered all of their
questions; etc. There are two standards for
disclosure depending upon the applicable law
regarding the location of your practice. The
more traditional standard is the professional
based one holding that the only information
you need to disclose to your patients is the
information that would usually be disclosed by
other doctors under the same or similar cir-
cumstances. The more modern approach is the
patient need to know standard wherein one
must give the patient all of the information that
a reasonable person in the patient’s position
Communications as an orthodontic risk management tool 137
138 Jerrold

would deem material in order to make a
decision to accept or reject the proposed
treatment.
From a communications perspective, the
information can be given by anyone in the office
and in almost any medium. Each of us should
develop our own style of information
transmission. Some practitioners will go high
tech via computer imaging and prepackaged
interactive CD programs, or proprietarily pro-
duced videotapes. Others will find that educa-
tional brochures or forms work best. For some, a
good old-fashioned conversation with the patient
is the way to go. How it is done and by whom is
Communications as an orthodontic risk management tool 139
140 Jerrold

irrelevant; the key is to ensure that regardless of
the method of communication or who actually
does the communicating, the patient or parent
understands the information being trans-
mitted. It is important to understand that we
don’t give informed consent. What we give a
patient is the required material information
and what we receive in return is their informed
consent.
How do we prove that this communication
transpired? We document it in some fashion.
These methods of documentation, think of them
as return communications, take the form of
videotaping or audiotaping the discussion;
Communications as an orthodontic risk management tool 141
142 Jerrold
 Communications as an orthodontic risk management tool 143

having the patient acknowledge they have read notations made by the doctor in the patient’s
and understood a variety of audiovisual pre- record as to the gist of the informed consent
sentations, forms, pamphlets, or letters; or discussion. Form 7 is a common type of form
144 Jerrold

used for this purpose, highlights the material
risks associated with orthodontic treatment, and
asks the patient to verify that they have read and
understood each paragraph. Form 8 is a checklist
that can be used by those who wish to have more
interactive discussions and can be appended to
the patient’s record to indicate the topics cov-
ered. Form 9 is specific to TADs. Form 10 is
specific to limited treatment. Form 11 is specific
to interproximal reduction. Before treatment
Communications as an orthodontic risk management tool 145
146 Jerrold
begins, there is one final area of communications
that needs to be addressed. It is a nasty little area
that deals with money. Orthodontists engage in a
personal service industry that results in us being
handsomely compensated for our ministrations.
As part of this exchange, we have to follow certain
legal requirements because the payment sched-
ules that we create result in us extending credit
and doing so triggers certain consumer advisory
mandates. The bottom line is that orthodontic
consumers must be apprised of any finance
charges or interest charged on the “loan” we are
extending (our payment plan). In addition, we
often charge the patient additional fees for such
things as expenses incurred relating to the col-
lection of past due accounts including legal fees,
fees for returned checks, late payment fees, fees
for lost or excessive breakage of appliances,
missed appointment fees, etc.
The general rule is, if patients are not spe-
cifically advised of additional charges that may be
levied before they begin treatment, than those
charges should not be imposed or added on once
treatment has begun. Traditionally, this respon-
sibility has been handled through the use of a
contract letter (Form 12) that has more recently
been supplanted by using a Truth-in-Lending
Statement. (Refer Forms 13 and 14.) The bottom
line is that all fees, but specifically interest and/
or finance charges, are discussed with and
accepted by the patient prior to treatment.With
all of the administrative requisites out of the way,
we can now move further down the time line and
begin active treatment. Your intake form should
have provided you with the identity of the
patient’s other treating dental health care pro-
viders and you should have a stable of commu-
nication letters for various clinical situations that
unfold. The requisite communiqués include at a
minimum, a periodontal evaluation letter and a
caries exam note (already discussed in Forms 5
and 6), a surgical procedure prescription memo
(Form 15), and the like. While these forms are
merely examples of the type required, from a risk
management perspective, the only real require-
ment is to maintain a copy of all referral or
consultation communications whether sent or
received in the patient’s record.
There are times when all is not going as
planned. For these instances, you must have two
poor cooperation letters. The first is commonly
found in every orthodontic practice management
software program and need not be shown here. It
alerts the patient or parent that without the
necessary level of cooperation on their part,
treatment results may be compromised. It also
states that in the event the lack of cooperation
continues and rises to an unacceptable level, you
may be forced to either discontinue treatment
prematurely or terminate the doctor–patient
relationship altogether. The other communiqué
documents notification sent to the general dentist
that patient cooperation is lacking and request
that they intercede if at all possible. (Refer Form
16.) They too need to know that treatment may
be compromised and that there is the possibility
that treatment may be discontinued early because
of the poor risk–benefit ratio of continuing to
treat a non cooperative patient.
As noted previously, all clinical and admin-
istrative obligations we owe the patient are based
on the existence of a doctor–patient relationship.
This legally recognized relationship is easily
formed. Once a doctor consensually agrees to
treat a patient and the patient consensually
agrees to accept the doctor’s ministrations the
relationship has been established. The venue in
which advice or treatment is rendered and the
fact that money has or has not been exchanged is
irrelevant. This relationship is a type of contract
and as such, there are duties and obligations on
the part of each party, the doctor and the patient.
Our duties to our patients derive from pro-
fessionally accepted policies and procedures, the
dental practice acts governing where we practice,
codes of ethics, and legal precedent established
by the courts. The obligations our patients owe us
are limited to keep appointments, not dictating
that we perform inappropriate treatment, fol-
lowing instructions, paying for services rendered,
conforming to accepted modes of behavior, and
cooperating truthfully and in a timely manner
regarding all valid administrative inquiries.
While forming the doctor–patient relationship
is relatively easy, breaking it is somewhat harder.
The accepted reasons for the termination of a
doctor–patient relationship are (1) the patient is
cured and no further treatment is necessary, (2)
both parties mutually agree to end it such as in
the case of the patient relocating, (3) the doctor
or the patient dies (this includes disability and
displacement from the office), (4) the patient
decides to unilaterally terminate the relationship,
and (5) the doctor decides to unilaterally
 Communications as an orthodontic risk management tool
terminate the relationship. The first three are
almost never problematic. When the patient
decides to terminate the relationship there may
be some repercussions based on the reason(s)
but for the most part they are that the patient
who is unhappy with some aspect of the doctor’s
practice, usually administrative in nature, and
usually deal with subjective or financial issues.
When this occurs, the patient is effectively
abandoning the doctor and from a risk man-
agement perspective you need to tell the patient
that they still need continued care and you will
help them in any way possible in this regard. You
will want to have the patient sign an against
medical advice (AMA) form. (Refer Form 17.)
Reason 5 is far more problematic and deals
147
with those instances when the doctor wants
to unilaterally terminate the doctor–patient
relationship.
The six legally accepted reasons for unilateral
termination by the doctor are aligned with the six
contractual obligations that patients owe their
doctors. In essence, the patient is deemed to have
breached one or more of these obligations. They
are (1) the patient is not following instructions;
(2) that they are not keeping regularly scheduled
appointments; and or (3) they are attempting to
dictate inappropriate treatment, all of which
have the potential to negatively impact the ability
to achieve a successful result. Looking at it
another way, one could argue that the patient is
impairing the doctor’s ability to adequately
148 Jerrold
render appropriate care. The fourth reason is
that the patient is not conforming to accepted
modes of behavior (being threatening or abusive
in the office) thus negatively affecting the doc-
tor’s ability to provide a safe working environ-
ment for staff and patients alike. The fifth reason
for doctors to unilaterally terminate the doctor–
patient relationship is that the patient is not
cooperating with reasonable administrative
inquiries such as providing truthful medical
histories or not providing employment infor-
mation thus impacting your ability to be reim-
bursed by third party payers. The final and most
vexing reason occurs when patients do not meet
their financial obligations.
You are under no obligation to render treat-
ment without being compensated however the
one caveat is that you cannot terminate the
doctor–patient relationship based on financial
reasons if the patient is in extremis, which is
defined as exhibiting signs of infection, bleeding,
intractable pain, swelling, etc., (something is
medically wrong and needs to be treated), or
when they are at a particular stage of treatment
that is active in nature and if left unsupervised
may result in iatrogenic harm to the patient. In
these situations, your obligation is to stabilize the
patient via treatment, referral, and or removal of
the active appliances. Once the patient is “safe,”
unilateral termination may then be undertaken.
This holds even if permanent teeth have been
extracted so long as the patient’s clinical treat-
ment has been stabilized.
You must provide the patient with notice and
basis meaning they have to be informed of the
reasons you are choosing to terminate their care.
You must inform them that continued treatment
is still required and that you will help them to
obtain such care of they so desire. You must give
them an adequate period of time to seek sub-
stituted care and you must make yourself avail-
able for any emergencies or for referrals during
 Communications as an orthodontic risk management tool 149

this period of time. Finally, you must make their
records available to them or any duly designated
subsequent practitioner. Ideally, this should be
done in writing similar to Form 18.
In those instances where you and the patient
have decided to resolve your difference provided
you agree to refund a portion of the fee already
paid you, you need to have the patient sign a
release. (Refer Form 19.) While this will protect
you from further legal troubles when the patient
is of legal age, it is important to remember that
releases signed by parents on behalf of a child are
150 Jerrold

not binding on that child unless the release is
approved by a court of competent jurisdiction
such as a Family or Surrogates Court. Without
Court approval, even though the patient’s
parent signs a release, when the minor patient
reaches legal age he/she may then sue in his
own name. However, the reality is that usually
the return of money and the signed release is
the end of it.
Finally, if the patient declares bankruptcy and
names you as a creditor, whatever they owe you is
expunged. Understand that the doctor–patient
relationship is still in existence. You cannot dis-
miss a patient because they declared bankruptcy.
 Communications as an orthodontic risk management tool
However, as there is still treatment that needs to
be rendered, you should treat them like you
would any transfer case that needs to be com-
pleted. In essence, you should evaluate the status
of the case and determine what prospective
treatment still needs to be rendered. You can
then determine a fee for the remaining treat-
ment (no, you cannot incorporate the amount
protected by the bankruptcy courts). You now
present the patient with a new Truth-in-Lending
form or a new contract covering their financial
obligations from this point forward. If they refuse
151
to agree to the new fee, this lack of agreement
gives you the right to refuse further treatment.
Patients are free however to reaffirm their
financial obligation to you and may do so by
singing a reaffirmation agreement. (Refer Form
20) This must be a voluntary decision on their
part.
The various types of communications descri-
bed thus far have saved many an orthodontist
from having to undergo the trauma associated
with being a defendant in a malpractice suit. In
addition, even if one does have to go to trial,
152
utilization of the forms in question are often
sufficient evidence to either result in a favorable
defendant’s verdict or in some instances in which
negligence is found, to have the jury award
reduced as a result of comparative negligence on
the part of the patient. The caveat is that after a
certain number of warning letters have been
sent, you must act affirmatively regarding patient
dismissal. To do otherwise is to engage in what is
known as supervised neglect.
Now that active treatment is concluded, you
need to have four completion letters—two for
phase one treatment and two for comprehensive
treatment—in each case, one goes to the
patient/parent and one goes to the GP. Again,
they need to say essentially the same thing. The
Phase I letter (Refer Form 21) alerts both the GP
and the patient that (1) the first phase of
treatment has been completed, (2) the treatment
goals were or were not met, and (3) that the
patient will be kept under observation in order to
determine whether or not a Phase II will be
Jerrold
necessary. Everyone needs to be on the same
page that phase one was only that, it was not
comprehensive therapy, and was merely under-
taken to address a specific problem at a specific
point in time and that fully addressing the
patient’s orthodontic needs will occur after
completing a second phase of comprehensive
therapy.
The second set of letters Form 22 is again for
both parties and again outlines what was and was
not accomplished, what type of retention is
required and whether or not long-term obser-
vation is necessary and for how long. It should
also indicate who is responsible for moni-
toring any long-term/lifetime fixed retention
employed. Finally, it informs that patient that the
doctor–patient relationship ends with the con-
clusion of the period of retention. So far, we have
discussed various forms of communications that
one should have in the patient’s dental record.
The reasons for maintaining copies of all these
communications aside from the obvious risk
Communications as an orthodontic risk management tool 153
154 Jerrold
Communications as an orthodontic risk management tool 155
156 Jerrold

management ones are based on the Importance
of the patient’s record as a legal document that
serves the following purposes. First and foremost,
the patient’s record provides documentary evi-
dence of the evaluation and diagnosis of the
patient’s condition. Next, it reflects the treat-
ment plan chosen and the patient’s informed
consent to that effect. It also notes all treatment
rendered and by whom, including referrals,
consultations, and recommendations. It indicates
the results achieved and the retention modality
employed. The patient’s dental record memori-
alizes all communications with the patient, rel-
evant third parties, and all other concurrently
Communications as an orthodontic risk management tool 157
158 Jerrold
treating health care providers. Finally, the dental
record provides data for continuing education,
quality assurance, research, administrative func-
tions included mandated privacy laws, and
billing.
The final area of intra-office communications
deals with the area of employment law. It can be
an extremely taxing ordeal both financially and
emotionally to have to defend oneself when
charged with discrimination and/or unlawful
termination of a staff member’s employment. As
a small business employer, orthodontists must be
wary of this minefield as well as those relating to
our clinical activities. In this regard, you as the
employer should be performing staff perform-
ance reviews at least twice annually. Forms 23, 24,
and 25 are examples of evaluation forms and can
be easily adapted to suit the needs of most
practitioners. The bottom line is that you want to
have documentation of staff members who are
underperforming, evidence that you have given
them notification of any shortcomings, and have
these evaluations span a period of time during
which your staff will not be able to claim that they
did not have the time to correct or remediate any
noted deficiencies.While there are certainly
other intra-, inter-, and extra-office communi-
cations that occur on a daily basis, the ones
previously referred to have important risk man-
agement components. Properly structured and
worded these communications can mollify the
daily stresses associated with practicing in an ever-
increasing litigious atmosphere. Having your
practice management advisor or legal counsel
review your communication forms is an important
component of prudent contemporary practice.
 Seminars in Orthodontics
Future Issues
Vol 22 No 3 (September 2016)
ORTHODONTICS / PEDIATRIC DENTISTRY ISSUES OF COMMON CONCERN
George J. Cisneros, DMD, MMSc, Guest Editor

Recent Issues
Vol 22 No 1 (March 2016)
INTERACTIONS BETWEEN ORTHODONTICS AND ORAL AND MAXILLOFACIAL SURGERY
Jae Hyun Park, DMD, MSD, MS, PhD, Guest Editor
Vol 21 No 4 (December 2015)
ADVANCES IN CBCT DIAGNOSTICS WITH ORTHODONTIC TREATMENT: INTERPRETATION AND MANIPULATION
Onur Kadioglu, DDS, MS, Guest Editor
Vol 21 No 3 (September 2015)
ACCELERATED ORTHODONTICS
Mani Alikhani, DDS, MS, PhD, Guest Editor
Vol 21 No 2 (June 2015)
JUVENILE IDIOPATHIC ARTHRITIS AND TEMPOROMANDIBULAR JOINT INVOLVEMENT: AN INTERDISCIPLINARY APPROACH
Bjørn Øgaard, DDS, Dr Odont, Guest Editor
Vol 21 No 1 (March 2015)
INTERDISCIPLINARY MANAGEMENT OF THE ORTHODONTIC PATIENT
Pratik Kumar Sharma, BDS(Hons), MFDS, MSc, MOrth, FDSOrth, Guest Editor
Vol 20 No 4 (December 2014)
ALL ROADS LEAD TO ROME: NEW DIRECTIONS FOR CLASS II
S. Jay Bowman, DMD, MSD, FACD, FICD, Guest Editor
Vol 20 No 3 (September 2014)
PERIODONTAL-ORTHODONTIC INTERACTIONS
Ramzi V. Abou-Arraj, DDS, MS, Guest Editor
Vol 20 No 2 (June 2014)
AGE-APPROPRIATE ORTHODONTIC TREATMENT, PART II
Gerry Samson, DDS, and Elliott M. Moskowitz, DDS, MSd, Guest Editors
Vol 20 No 1 (March 2014)
AGE-APPROPRIATE ORTHODONTIC TREATMENT, PART I
Elliott M. Moskowitz, DDS, MSd, and Gerry Samson, DDS, Guest Editors
Vol 19 No 4 (December 2013)
THE VERTICAL DIMENSION IN ORTHODONTICS
Nada M. Souccar, DDS, MS, Guest Editor
Vol 19 No 3 (September 2013)
EVIDENCE-BASED ORTHODONTICS
Katherine Vig, BDS, MS, FDS, DOrth, and Greg Huang, DMD, MSD, MPH, Guest Editors
Vol 19 No 2 (June 2013)
PROGRESSIVE CONDYLAR RESORPTION AND DENTOFACIAL DEFORMITIES
Chester S. Handelman, DMD, and Charles S. Greene, DDS, Guest Editors
Vol 19 No 1 (March 2013)
INTERDISCIPLINARY TREATMENT OF ADOLESCENTS WITH MISSING ANTERIOR TEETH
Mark R. Yanosky, DMD, MS, Guest Editor
Vol 18 No 4 (December 2012)
UPDATES ON THE BIOLOGICAL FOUNDATIONS OF ORTHODONTIC TOOTH MOVEMENT
Vinod Krishnan, BDS, MDS, M Orth RCS D, PhD, and Ze’ev Davidovitch, DMD, Cert Ortho, Guest Editors
Vol 18 No 3 (September 2012)
AN OVERVIEW OF FACIAL ATTRACTIVENESS FOR ORTHODONTISTS
Margaret Collins, BDS, FDSRCPS, DOrth, MSc, MOrthRCS, MA, Guest Editor