SAO_Fall_06 by shuifanglj


									Fall 2006

S   O U T H E R N   A   S S O C I A T I O N   O F   O   R T H O D O N T I S T S
            SAO NEWS
   A publication of the Southern
    Association of Orthodontists
          32 Lenox Pointe
     Atlanta, GA 30324-3169
 (404) 261-5528 or (800) 261-5528                       Table of Contents
        Fax: (404) 261-6856
     Web site:

           OFFICERS                        FEATURES
             President                        AAO Trustee’s Report                                           3
      Richard McClung (WV)                   by Mike Rogers, DDS
           President-Elect                     Public Awareness Exposure, Are You Ready?                     5
        David Williams (TN)                  by Alan Helwig, DDS, AAO Council on Communications
          Jay Whitley (LA)
                                               Pioneers of the Specialty                                     8
                                               One Year After Katrina                                       10
            Past President
          Steve Garrett (VA)                   Are You Prepared?                                            14
     SENIOR DIRECTORS                          2007 SAO Calendar                                            27
      First Senior Director
      Mark Johnston (GA)                       2006 Annual Meeting Schedule                   Inside Back Cover
       Second Senior Director              CLINICAL
          Tim Trulove (AL)                    Evidence-bolstered Orthodontics                               16
                                              by James L. Ackerman, Martin R. Kean, and Marc B. Ackerman
        Third Senior Director
         R. R Reed, Jr. (FL)                   Cranofacial Dynamics Explored                                18
                                               by Jorge C. Coro, DMD, MS
          AAO TRUSTEE
       Michael B. Rogers (GA)              CASE REPORTS
                                             Category #7 for Recertification presented                      20
       Joseph LeCompte (FL)                  by James A. High, DDS
       EDITORIAL BOARD                         Category #7 for Certification presented                      23
          Jeremy Albert                        by Dallas Margeson, DDS
           John Beattie
          David Paquette                   STAFF CORNER
            Jim Vaden
                                              Collection Processing in the New Millenia                     28
        Sharon Hunt, CAE
                                              by Brenda Cooper-Vogeley
         (800) 261-5528
            Founded in 1921
   Fostering the Ethical Delivery of
       Quality Orthodontic Care
 SAO News is published twice a year
    by the Southern Association of
Orthodontists. The opinions expressed
 in articles and editorials are those of
the authors and not necessarily those
           of the Association.


Trustee’s Report

                                                                                      Trustee’s Report
by Mike Rogers, AAO Trustee

    have enjoyed serving as your AAO Trustee for the last
    four years. I continue to represent the AAO in the follow-
    ing areas:
• Board of Trustees’ liaison to the Council on Insurance
• Chairman of AAO/ABO Committee
• Chairman of AAO Disaster Relief Fund
• Chairman of the Access to Care Committee                        Mike Rogers,
                                                                  AAO Trustee
• ADA Advisory Committee and the ADA Reception
• 2007 Leadership Conference Committee
• AAO Endorsed and Approved Services and Products Review Committee
• Impact of Annual Sessions Committee
• Orthodontic Vendor Product Claims Committee
• Board Committee B
     The AAO will continue to be your number one advocate, and your input is
always welcome and needed to help stay on top of the issues. Please feel free to
contact me with any advice or concerns.
Congratulations to our SAO Delegation
                                                         The SAO Delegation
                                                    under the direction of Chair-
                                                    man Buddy Foy and Vice-
                                                    Chairman Page Jacobson did
                                                    an outstanding job represent-
                                                    ing your interests at the Annu-
                                                    al Meeting in Las Vegas.
                                                         A report of the House of
                                                    Delegates actions can be
                                                    found on the AAO web site
                                                    in the AAO Bulletin and the
                                                    SAO News, but I want to list
                                                    several of the important reso-
                                                    • A budget of $19,845,385
                                                    approved while maintaining a
                                                    reserve of 75% of the opera-
                                                    tional budget.
                                                    • Approved a two year $3.87
                                                    million Public Awareness
                                                    • Waived the Annual Session
                  Dr. Buddy Foy                     Fee for full time orthodontic
• Eliminated the Associate Member Category which makes orthodontists eligible as
active members immediately upon graduation. An application is sent to the AAO
and processed for approval by the AAO Board of Trustees.
• Expanded the Student Membership Category to include students when they are
Fall 2006                                                                                                                                       SAO

ACCEPTED in an accredited orthodontic program. Previ-                              dentistry and orthodontics
ously they had to be enrolled. The AAO wants to wel-                               2. Based on their review of relevant data, they will recommend
                                                                                   action items to positively influence the future of orthodontics
come the students immediately.                                                     3. Examining future trends in the globalization of orthodontics
• Revised the Membership Application to make it a stan-                            and orthodontic education
dard generic application.                                                          4. Prioritizing future direction goals and issues
• Passed a resolution to allow former members to be rein-                          5. Studying and making recommendations on future AAO initia-
                                                                                   tives and involvement in access to care issues
stated one time by paying the current dues and assess-
                                                                                   6. Identifying any areas that were not considered at the SAO
ments. Previously former member had to pay all back                                strategic framework
dues and assessments.                                                              7. Developing future leaders
• Passed a resolution to augment faculty salaries and ben-                         8. Examining the AAO Strategic Plan and its relationship to this
efits. The AAO allocated $2 million in the 2006-2007                               issue
                                                                                   9. Continuing to look at all aspects of the future of orthodontics
budget to augment faculty salaries and benefits at all                             through consultants and workshops
accredited postgraduate orthodontic residency programs in                          10. Reporting to the House of Delegates and Board of Trustees
the USA and Canada. The funds came from excess                                     minimally on an annual basis
reserves; and at this point, this is a one time allocation.
• Approved a Future Directions Standing Committee
                                                                                   Budgetary Implication: $40,000
Future Directions Standing Committee
    As mentioned above, a Future Directions Standing                               The SAO Executive Committee
Committee was approved by the House of Delegates.                              selected Dr. Britt Visser of Virginia
This resolution was written and sponsored by the SAO                           Beach, Virginia, to represent the SAO
and this committee is a direct response to the strategic                       on this committee.
planning facilitated by the Institute for Alternative Futures
which wrote Anticipating the Forces of Change in                               AAO Two-Year Public Awareness
Orthodontics report for the SAO. Your SAO leadership                           Campaign
wanted to make sure that the AAO continued to plan for                              The 2006 House of Delegates
the future. The resolution reads as follows:                                   approved an annual $3.87 million Pub-         Dr. Britt Visser
                                                                               lic Awareness Campaign. Funding for the campaign is
    RESOLVED, that the AAO form a 14-member Future Directions                  primarily through a $450.00 per member dues assessment
    Committee as follows:                                                      with the remaining $420,000 funded from the Association
    The committee will consist of one member from each constituen-
                                                                               reserves for this year.
    cy appointed by the constituency with consideration for diversity               Currently, the campaign is still in the developmental
    of representation. Members so selected will serve for a maximum            stage. Schupp Company will be managing the campaign
    of four years and will be selected on a rotational basis between the       and plans to begin the process of purchasing magazine,
    constituencies with initial appointment drawn by lot, ie., represen-
                                                                               cable TV and Internet advertisements soon. The media
    tatives from two constituencies will be appointed to each of 1, 2, 3
    and 4 year terms respectively. In addition, two members of the             purchased will cater to women ages 25-54 who have chil-
    Council on New and Younger Members, two orthodontic depart-                dren in the household.
    ment chairmen selected by the AAO Board of Trustees; and two                    The “More than a Smile” commercial will promote
    trustees appointed by the AAO President annually, one of which             the unique qualifications of AAO-member orthodontists
    will be the Chair of the AAO Strategic Planning Committee,
    will serve on this committee. The chairman will be selected by
                                                                               and will be carefully reviewed by the AAO Board of
    majority vote of the committee from among the constituency                 Trustees, the AAO Council on Communications, the
    representatives.                                                           AAO’s executive director and general counsel.
                                                                                    The AAO leadership has identified consumer aware-
    The committee will have one face-to-face meeting in conjunction
                                                                               ness as a critical issue that needs to be addressed and has
    with the Leadership Conference and will be re-evaluated by the
    2007 House of Delegates to determine if the committee should be            specifically listed it in the AAO Strategic Plan.
    continued. This committee will be facilitated by a professional                 Dr. Alan Helwig ( ), your SAO
    consultant selected by the Board of Trustees.                              representative on the Council on Communications, will be
                                                                               happy to answer any questions for you. See his report on
    The committee will be charged with the following:
    1. Reviewing the SAO Future Directions project, AAO Strategic
                                                                               page 7.
    Plan, ADA and other studies and papers related to the future of

SAO                                                                                                                Fall 2006

Task Force on Recruitment and Retention of                             Please refer to the AAO (
Faculty                                                           for rules concerning all usage especially on printed materi-
     A Task Force has been formed to study all issues on          als, exterior and interior building signage, and Web sites.
the recruitment and retention of faculty. The eleven mem-
ber Task Force is made up of three members of the AAO                 SIGNAGE/DISPLAY
Board of Trustees, two members of the AAO House of                    The following logo/signage and display items are
Delegates, four Orthodontic Educators, and two Dental             available from the AAO:
Deans. The members are the following:                                 ✔ Desktop sign for reception counters or desks
• Raymond George, Sr.; Chair of the Task Force and AAO                ✔ Business card holders
  Secretary-Treasurer and Trustee                                     ✔ Pamphlet racks
• Lee W. Graber, Trustee                                              ✔ Magazine covers
• David L. Turpin, Board member and AJO/DO
                                                                  AAO 2007 Leadership and Governmental Affairs
• Brent E. Larson, Delegate to AAO House of Delegates             Conference
  and Orthodontic Dept. Chair of the University of                     The 2006 AAO Governmental Affairs Conference was
  Minnesota                                                       cancelled because Congress voted to recess during the
• Leslie A. Will, Delegate to AAO House of Delegates and          week of the conference. Because of the recess the AAO
  Orthodontic Dept. Chair of Harvard School of Medicine           determined that the conference would not be effective
• Rolf G. Behrents, Orthodontic Educator Category:                since interaction with congressional leaders on Capitol
  Orthodontic Dept. Chair of Saint Louis University               Hill visits could not take place since most of the represen-
• Katherine Kula, Orthodontic Educator Category:                  tatives and senators would be in their home districts.
  Orthodontic Dept. Chair of University of Missouri –                  It was decided that the Governmental Affairs Confer-
  Kansas City                                                     ence would be combined with the 2007 Leadership Con-
• William R. Proffit, Orthodontic Educator Category:              ference and moved from St. Louis to Washington, D.C.
  Past Orthodontic Chair of University of North Carolina          The conference is scheduled from Sunday, January 28th to
  and current faculty member                                      Wednesday, January 31st. On Sunday morning, the Presi-
• James L. Vaden, Orthodontic Educator Category:                  dent-Elect’s session begins with an update on AAO activi-
  Orthodontic Chair of University of Tennessee                    ties along with leadership training. Several congressional
• James J. Koelbl, Dental Dean Category: Dean of West             leaders will address the group during the conference and
  Virginia University School of Dentistry                         former Speaker of the House Newt Gringich will present a
• William K. Lobb, Dental Dean Category: Dean of                  two-hour session on leadership development. The confer-
  Marquette University School of Dentistry                        ence will conclude on Wednesday with Capitol Hill visits
• Anita Craig, AAO Staff Liaison                                  emphasizing AAO positions. This will offer an excellent
     The Task Force is charged with examining all aspects         opportunity for the AAO to train all the attendees on lead-
of recruitment and retention of faculty. You are invited to       ership and advocacy skills.
provide input by contacting any of the task force members.        2007 AAO Interdisciplinary Conference
Logo Manual Revisions                                                  The conference will be held February 9-11 at the
     The House of Delegates passed revised logo usage as          Hyatt – Esmeralda Resort in Indian Wells, CA. This two
follows:                                                          and one-half day meeting is intended to attract teams of
     Any member in good standing except honorary mem-             orthodontists, surgeons, restorative dentists, and periodon-
bers may use their respective AAO logo in TV advertising,         tists who either work together in a teamwork fashion to
newspapers, magazines, yearbooks/annuals, and in the              manage interdisciplinary cases, or who want to learn how
telephone directories, except that the logo may not be used       to develop a team. Each featured team will be assigned a
in conjunction, or shown, with more than one member or            topic and will have about one-hour to cover that topic with
practice of members in any telephone directory advertise-         all members of the team contributing to the presentation.
ment (i.e. group listings of unaffiliated members are not         At the end of each morning and afternoon session there
allowed). AAO members who elect to advertise must do              will be a half-hour panel discussion with questions from
so consistent with all applicable ethics rules promulgated        moderators and the audience. The specialty speakers will
by the AAO and the American Dental Association.                   each have one-half hour to deliver an update on what is

Fall 2006                                                                                                                  SAO

 new in their area of dentistry.
 The Team and Specialty Speakers are as follows:                     You are invited to strengthen your team by inviting col-
 CONFIRMED TEAMS:                                                    leagues. Online registration opens in August 2006.
 1. Kokich (ortho), Spear (pros), Mathews (perio) –
    Seattle, WA                                                      Jeff Lindsey Leads the ADA Council on Members
 2. Sarver (ortho), Dudney (pros), Rousso (surgeon) –                Insurance and Retirement Programs
    Birmingham, AL
 3. Salama (ortho), Salama (perio), Garber (pros) –                       In continuing my tradition of recognizing an outstand-
    Atlanta, GA                                                      ing SAO member in every Trustee’s Report, I want to
 4. Roblee (ortho), Allen (perio), Winter (pros) –                   acknowledge Jeff Lindsey of Carrollton, Georgia for his
                                                                     service on the ADA Council on Members Insurance and
                                                                     Retirement Programs. He is currently Chairman and was
                                                                     appointed to represent the Fifth ADA District four years
                                                                          The Council’s duties include: to evaluate all Associa-
                                                                     tion-sponsored insurance programs; to examine and eval-
                                                                     uate other insurance programs that might be of benefit; to
                                                                     advise and recommend courses of action on insurance
                                                                     programs; to assist constituent societies in matters related
                                                                     to insurance programs; and to serve as Trustees for the
                                                                     ADA Members Retirement Program, which currently has
                                                                     $1.3 billion in assets.
                                                                          As Chairman of the Council, his duties are to develop
                                                                     the budget for the Council, to provide letters to the plan
                                                                     participants or the general membership that are sent
                                                                     under the Council’s auspices, and to preside over the
  Jeff Lindsey, center, leads the ADA Council on Member Insur-       meetings of the Council. As Chair, he also serves as a
        ance and Retirement Programs at a recent meeting.
                                                                     conduit for Chairs of other ADA Councils in matters that
                                                                     may relate to the Council on Members Insurance and
    Dallas, TX                                                       Retirement Programs. He has served on the Council as
 5. Joondeph (ortho) and Bloomquist (surgeon) –                      the Fifth District representative since 2002 and will rotate
    Seattle, WA                                                      off the Council after this year’s annual meeting. He states,
 6. Kokich, Jr. (ortho), Kinzer (pros), and                          “It has been an enjoyable four years, and I am honored to
    Janakiewski (perio) – Seattle, WA                                have had the opportunity to serve and truly learn how
 7. Celenza (ortho) and Celenza (pros) – New York, NY                valuable the ADA is for dentistry.”
 8. Alexander (ortho) and prosthodontist –                                I thank Jeff for his leadership. Serving in ADA posi-
    Colorado Springs, CO                                             tions is important because of your expertise and because
 9. Zachrisson (ortho) and Toreskog (pros) –                         it gives orthodontics a stronger voice in ADA matters.
    Oslo, Norway                                                     Please serve at the local, state, and national ADA level
                                                                     if the opportunity is presented.
 1. Orthodontics – David Turpin (University of Washington)
                                                                      Have an idea? Have a comment? Want to make a
 2. Periodontics – Roy Page (University of Washington)
 3. Surgery – James Swift (University of Minnesota)                   suggestion? Contact me at
 4. Restorative – Gerard Chiche (Louisiana State University)                (706) 733-1182, (706) 733-2501 fax
                                                                          3545 Wheeler Road, Augusta, GA 30909.

SAO                                                                                                               Fall 2006

Public Awareness Exposure, Are You Ready?
by Alan Helwig, DDS, AAO Council on Communications

       he 2006 HOD overwhelmingly approved the Con-               firm working on the consumer
       sumer Awareness Campaign, so now what can you              awareness campaign, will work to
       expect? The campaign will utilize three different          make certain that the AAO and
mediums to educate consumers about the unique qualifica- comes up at the
tions of the AAO-member orthodontist. The message is              top of Yahoo and Google searches.
this:                                                             A budget of $318,000 will be
     Orthodontists receive two to three years of additional       spent on the two priority test mar-
university education beyond dental school to learn the            kets (Providence, RI and Salem,
proper way to align and straighten teeth.                         OR).
     The “More than A Smile” marketing idea that you saw               If you have any questions,
in a DVD that was inserted in your Spring Bulletin is now         concerns or feedback, both posi-         Alan Helwig, DDS
being developed into a commercial for cable TV a magazine         tive or negative, please share it so we can make this cam-
print ad, and developed into a Web banner that will appear        paign beneficial to our profession and you. You can
on sites that are visited by the AAO’s target audience.           contact me at 703.356.2173 or
     You can expect to see the ads in October, November,
and December of 2006. The following cable TV
networks, national magazines, and Web sites
have been identified as being appealing to the
target audience: mothers who are ages 25-54
with children in the household. Watch for the
ads on the following stations, in the following
magazines, and on the following Web sites:
($921,941 budget)
    ABC Family Channel, Cartoon Network,
CNN (Cable News Network), Discovery Health
Channel, E! (Entertainment Television), Food
Network, HGTV (Home & Garden TV), Life-
time, Lifetime Movie Network, Nick at Nite,
Nickelodeon, Oxygen, TLC (The Learning
Channel), Toon Disney, and WE (Women’s
MAGAZINES ($780,476 budget)
    Womans’ Day, Ladies Home Journal, Par-
enting, Family Fun, Today’s Parent (Canada),
and Canadian Family (Canada)
INTERNET BANNERS ($380,000 budget)
    Below are a list of sites Corinthian is rec-
ommending to test with due to their high com-
position of the AAO target demographic:
iVillage, FamilyCircle, Mayo Clinic, BHG, Par-, Healthy Kids, and WebMD
    Schupp Co., the marketing communications

Fall 2006                                                                                                              SAO

Pioneers of the Specialty

        his issue of the SAO
        News will honor two pio-
        neers of the specialty
who have shown many of us the
nature of servant leadership—
they were visionaries and they
got things done. Of equal
importance is how they demon-
strated the spirit of community
that is a core value of the
Southern Association of
Orthodontists.* These pioneers
practiced in different states, but
through orthodontic connec-
tions, they met each other and
became steadfast friends, one of
the greatest gifts that the SAO
can give you. The two pioneers
are Russell Greer (KY) and
Ralph White (TN).
     Russell Greer, a SD (son of
a dentist), made several stops on                Russell Greer, DDS                              Ralph White, DDS
his way to becoming an
orthodontist. After receiving his dental degree from the            • Set in motion the idea to hire an executive director.
University of Tennessee in 1951, he spent two years prac-           • Recommended that the public relations program
ticing general dentistry and then two years in the Dental           (sound familiar?) started in 1975 be continued and
Corps of the U.S. Air Force. In 1956 he returned to UT for          expanded as deemed advisable.
his Master of Science in Orthodontics. He eventually set-           • Encouraged starting a society-wide program of
tled in Lexington, KY in 1959 to practice orthodontics.             orthodontic care for the deserving indigent through the
Since that time he has given many hours of labor and love           free enterprise system of health care.
to dental organizations. Russell has served as president of         • Tackled the third party payment system by suggesting
Kentucky Board of Dentistry, Bluegrass Dental Society,              a workshop to address issues and a hot line to answer
North American Begg Society of Orthodontists, Southern              questions.
Society of Orthodontists,* and the American Association             • Recognized individuals who had worked for the
of Orthodontists.                                                   society.
     With that history out of the way, what did Dr. Greer             In the AAO, Dr. Greer supported quality of care pro-
REALLY accomplish? Lots. Let’s start with the SAO.                vided by orthodontists. As Russell said, “assuring quality
   • Redesigned the governance structure to include all           orthodontic care has always been a primary concern and
   components (state orthodontic organizations). As noted         objective of the AAO…The multitude of intraprofessional
   in the SSO* History, “the effects of this highly signifi-      and extraprofessional concerns dictates that possible meth-
   cant change in the size and composition of the society’s       ods of quality assessment and quality assurance be reeval-
   principal governing body were far-reaching. It was an          uated at all levels of the dental profession and the
   unprecedented step toward more representative govern-          orthodontic specialty. Neither quality assessment nor
   ment for the society.” This was accomplished 40 years          quality assurance should be directed by third parties such
   ago. Some other constituent (regional) orthodontic orga- as insurance companies and/or state or federal regulatory
   nizations still do not have all states recognized to the       agencies.” (Orthodontics at 2000 by Eric Curtis, AAO,
   extent that they are in the SAO.*                              2000, p. 49)
SAO                                                                                                              Fall 2006

     Also, as AAO President, Dr. Greer moved the AAO               think of Ralph: basic human kindness, remarkable atten-
Board into high technology by developing email capabili-           tion to detail, and patience…There is a fourth quality
ties. Four trustees were asked to buy laptop computers             which I admire, also. He is a man devoted to his wife and
and printers (with their own money) and evolve an elec-            family.” These remarks were prepared for Dr. Greer’s
tronic communication protocol.                                     citation for Dr. White to receive the James E. Brophy
     Using a different leadership style, Dr. Ralph White set       AAO Distinguished Service Award, which Ralph did in
about changing the policy and process of the organiza-             1993.
tions that he served. A native of Tennessee, Ralph also                 When Ralph served as SSO* president, his theme was
received his dental and orthodontic education at UT and            “Only as Colleagues…” and concluded his remarks by
served in the U.S. Army Dental Corps for two years. He             saying,
opened this orthodontic practice in Kingsport, TN in                  • Only as colleagues, can we continue our proud SSO*
1962.                                                                 legacy.
     Ralph served tirelessly on many state, regional, and             • Only as colleagues, can we strengthen our unity of
national committees/councils of dental organizations.                 purpose and effect unification of our profession.
While Ralph served as president of several dental organi-             • Only as colleagues, can we uphold the highest ideals
zations (TAO, SSO*), his role was to fine tune and to                 of professionalism.
direct. In 1987, while serving on the AAO Board of                    • Only as colleagues, can we achieve our goal of pro-
Trustees, he proposed a highly significant research pro-              viding the best orthodontic care and treatment for our
gram to determine whether there is a relationship between             patients.
orthodontic treatment and TMD. His was an effort to                   • Only as colleagues, can we effectively influence the
shed scientific light on one of the most emotionally                  direction of our future.
debated topics of that time. This culminated in research              • Only as colleagues, can we make things happen.
findings published in the January 1992 Special TMJ Issue                Dr. Greer and Dr. White provide the linkage to our
of the AJO/DO which contained 13 original articles. He             orthodontic community in the SAO*—by telling us how
wrote an AAO position paper on educational programs for            to build community, by demonstrating how to live as a
comprehensive orthodontic treatment which was adopted              community, and by linking together to pioneer the path to
by the House of Delegates. Ralph knew no peer when it              a better orthodontic community.
came to writing or rewriting bylaws, policies, and proce-
dures. Ralph also served as AAO Speaker of the House                  NOTES: *We refer to SSO (Southern Society of
of Delegates in 1995 (served as Speaker of the House of            Orthodontists) and SAO (Southern Association of
the TDA for seven years).                                          Orthodontists). The name, “Society” to “Association,”
     As leader, Ralph served as president of the SSO* and          was changed in 1988. The American Society of
initiated the first Future Directions Committee, which has         Orthodontists was changed to the American Association of
become an ongoing influence in shaping SAO* organiza-              Orthodontists in 1934.
tional goals and strategies.
     Former SAO* Executive Director John Ottley wrote                  Both Russell and Ralph were adventuresome and took
of Dr. White, “three qualities stand out in my mind when I         the SSO meetings to exotic places—Bermuda and Hawaii.

  Employing Children
  Parents who conduct business as a sole proprietor or partnership may find a substantial tax
  savings if they can employ their children. This will almost always result in income being
  shifted from a higher-bracket taxpayer (i.e., the parent) to a lower-bracket taxpayer (i.e.,
  the child). Earned income is not subject to the "kiddie tax." However, wages paid by a
  parent to a child who is older than 18 and employed in the parent's trade or business
  are subject to social security taxes.

Fall 2006                                                                                                                        SAO

  One Year After Katrina

       or all living souls, there is a defining event that             than Camille back in 1969. Katri-
       changes their lives forever. Hurricane Katrina and              na covered an area 200 miles wide
       her sisters will forever define the lives of people liv-        by 200 miles long. We had winds
ing in Mississippi and Louisiana. Some of those affected               in the Hattiesburg area, 65 miles
persons are members of the SAO. We contacted these                     from the Gulf Coast, of over 120
members via email to see how they are doing one year                   miles per hour and associated tor-
later. The questions asked were as follows:                            nados. All power, phones, TV
1. To what extent was your personal life affected by                   cable were off from two weeks to
2005 Hurricanes (and which hurricanes wrought the                      three months. Water was off for a
most damage)?                                                          week. We had a seven week peri-
2. To what extent was your office(s) affected by 2005                  od after the storm with no rain       Dr. William (Billy) McKinley
Hurricanes?                                                            and over 100 degree tempera-
3. How have the hurricanes affected your practice?                     tures. I found out I was a diabetic three months after the
4. How much assistance did you receive and from whom?                  storm. Don’t know if the storm was a contributing factor
5. What assistance was the most helpful to you?                        but suspect it was…sleeping at night was a reminder of
6. On a scale of 1-10, how close are you to being “back to             what it was like before air conditioning until we got genera-
normal”?                                                               tors to run fans. No water to take baths or wash clothes.
7. Reviewing your experience of the past year, what tips               Reminded us of what the troops in the Middle East must
would you offer to someone to prepare for an impending                 endure daily.” Dr. McKinley goes on to say, “for the first
natural disaster (assume you have 24 hours notice)?                    week after the storm, we and our neighbors ate and drank
                                                                       like kings and queens as we cooked everything in our freez-
    We did not receive many responses (communication                   ers. Everyone shared everything; shrimp, lobsters, steaks,
issues?), but the responses we received were excellent as              all sorts of vegetables, desserts, etc. After a week, it was
you will see below.                                                    pork & beans, sardines and Vienna sausage!”
                                                                            Dr. Kay Daniel (New Orleans, LA) feels that she
     The members who suffered heavy damage and disrup-                 fared better than some. Her New Orleans office was
tion of lives deserve praise for fortitude and grittiness of           closed for four months; her Slidell and Mandeville offices
spirit to rebuild their homes, practices, and lives. Dr.               were closed for about four weeks. Her income from the
William (Billy) McKinley (Hattiesburg, MS) gives a vivid               Northshore offices more than made up for her lost revenue
description of the power of Katrina – “Katrina was worse               from the New Orleans office. She did lose her house (pic-

SAO                                                                                                              Fall 2006

                                                                a day were fed). On the very first day of his volunteer ser-
                                                                vice, a Red Cross staffer came to Lee with a dental emer-
                                                                gency; so Lee organized a dental relief plan in which every
                                                                dentist in the area participated. When an evacuee presented
                                                                to the Red Cross medical team with a dental need, the Red
                                                                Cross would send him/her to a dental office with a paper
                                                                sticker which was presented at the dental office for service,
                                                                thus assuring that the patient burden would be spread
                                                                around the dental community evenly. The dentists provided
                                                                emergency service at no charge. In the case of orthodontic
                                                                patients, Dr. Engel treated most evacuees for several
                                                                months before they returned to the coast or relocated else-
                                                                where. However, Dr. Engel is still treating some patients
                                                                who do not have funds to move on.
                           tured above) due to 10 pine trees         Dr. Alan Querens (Metairie, LA) reports that his
                           falling on it. She was lucky to      office and personal residence had no damage “due to natu-
                           find a rental home after the         ral process or government incompetence.” Ninety percent
                           storm. Dr. Richard Ballard’s         of his patients returned. He reports that every practitioner
                           (Mandeville, LA) home was            left in the area is doing great business.
                           destroyed and he lived with his           While on the topic of government response, Dr. Sandy
                           in-laws for six weeks until he       Rushing (Jackson, MS) reported that his son’s home in
                           could find a house to rent. Dr.      Waveland, MS was severely damaged. The son is now liv-
                           Sam Mayfield (Gautier, MS)           ing in a FEMA trailer, which was provided a few weeks
                           lost four homes, a boat and two      after the storm, free of charge, while getting their lives
       Dr. Kay Daniel      cars. Since there was no place       back on track. Dr. Rushing was without power for one
                          to live, he bought a small RV and     week, but suffered no damage to home or offices. He was
moved into a RV park and lived there for 10 months, until       surprised how forceful the storm was 150 miles inland.
he could move into a renovated house.                                Dr. John Stringer (Gulfport, MS) had rebuilt after
     The responses indicated that Katrina did not affect        Hurricane Camille on ground higher than the highest
everyone the same way. Dr. Andrew Nalin (Bossier City,          Camille mark, a storm to which he lost a residence. He
LA) reported about 10 minutes of rain from Katrina and          and his son’s home came through the storm with minimal
no damage from the other storms. Dr. Jay Whitley                damage, mostly from tree limbs.
(Baton Rouge, LA) was affected most by the evacuee
traffic, although he was without electricity for several
days. However, minimal effect was not the norm for many.
     Dr. Lee Engel (Greenville, MS) was not affected physi-
cally by the storm. However, his practice was touched as
his office was given the opportunity to respond to Katrina
by helping victims. Many evacuees from the coast got to
                            Greenville and stayed because
                            that was where they ran out of
                            gas. On all the major routes
                            north in Mississippi, there were
                            “make shift cardboard” signs
                            denoting shelters, most of them
                            operated by the Red Cross. Lee
                            and his family were volunteers                        John and Nelda Stringer
                            at the Greenville shelter where
                            about 250 people were housed        Effect on Offices, Patients, and Staff
                            and provided with three meals a        While many offices were damaged by the storms, the
       Dr. Jay Whitley     day (sometimes up to 500 people      good side was that some orthodontists chose to close

Fall 2006                                                                                                                  SAO

unprofitable locations and channel patients to profitable           tors and other segments of the population. As with
locations when the practice reopened. Some practices                patients, some staff relocated to other parts of the country.
were able to reopen after two weeks, others were closed for         As Dr. Daniels said, “this was a blessing because some
months. Dr. James Woods sold his practice in Gulfport,              orthodontists had a reduced workload for several months.”
MS, and now lives in Clemson, SC. He is looking for                 Dr. Dubroc is married to his staff – not an issue. He says
opportunities in South Carolina as he has a license to prac-        it reinforces the idea that smaller can be better. Dr. May-
tice in that state. As he says, “my wife and I were simply          field’s staff suffered significant damage to homes. One is
tired of running from storms after so many years.”                  still in a FEMA trailer. Dr. Mayfield made sure that his
Dr. Guy A. Favaloro (LaPlace, LA) said that several                 staff never missed a paycheck and he gave them a disaster
orthodontists made the decision to permanently leave the            bonus to help them get back to normal...or as normal as it
state, resulting in an increase in transfer patients that has       can be. Dr. Woods’ staff was uprooted, had housing dam-
since leveled off. Dr. Phuong Nguyen (New Orleans, LA)              ages, and had to move. Dr. Favaloro was fortunate not to
lost 50 percent of his patient base. His office was located         lose staff.
inside the LSU Dental School; so presently he is sharing
                                                                    Assistance and Insurance
space with an orthodontic resident at an alumni’s practice.
                             One of the silver linings in the            Dr. Dubroc received grants from the American Dental
                             aftermath of Katrina was den-          Association and the Louisiana Dental Association. Busi-
                             tists/orthodontists pulling togeth-    ness interruption insurance covered lost income through
                             er and sharing space in offices        the period of interruption. Business contents insurance
                             that were not damaged.                 will pay for replacement of cabinetry, etc. He did not
                                  Dr. Glenn Dubroc’s office         request assistance from the American Association of
                             was closed for four months.            Orthodontists because the application specified that it was
                             Since re-opening his office pro-       for losses not covered by insurance. Dr. Dubroc says that
                             ductivity (i.e. case starts) is the    business interruption insurance was the savior and every
                             same or slightly better compared       doctor should read the terms of this policy and be aware
                             to 2005; however, new patient          of exact coverage limits and exclusions.
                             examinations are down 45 per-               Dr. Nguyen received insurance for damage to his
    Dr. Guy A. Favaloro
                            cent compared to last year. He          home with timely payment from his insurance company.
attributes this to (1) the vast majority of referring general       Dr. Favaloro did not ask for any assistance. Dr. Ballard
dentists are still borrowing office space and thus only             appreciated the assistance from ADA, AAO, SAO, FEMA,
working 1-2 days per week; (2) the families in the commu-           Red Cross, and insurance. MDA waived Dr. Mayfield’s
nity from his patient base are not congregating at ballparks        dues for the year.* He received $2,500 from FEMA as
and social events the way they used to and if they do get           did everyone in the area. He attended a disaster recovery
together, they share storm stories, miseries, etc. instead of       seminar for dentists sponsored by Schein-Sullivan in
“who is your orthodontist.”                                         Jackson. It was a great help to those who attended.
     Dr. Mayfield had a beautiful 1898 restored Victorian           FEMA reimbursed Dr. McKinley for a generator and a
home for his main office. He lost everything in that office.        chain saw. With some stern negotiating, Dr. McKinley
He had files dried commercially and made copies of treat-           was able to get insurance to pay for a new roof and
ment sheets and patient detail for the computer. He made            repairs. To Dr. McKinley, the greatest assistance was
new folders and placed the “smelly” ones that had been              neighbors pulling together and sharing. Dr. Daniel
soaked in a closet with a humidifier running 24 hours a             received assistance from the LDA and the ADA, which
day. He waived all late fees and missed appointment                 helped cover staff salaries.
charges for the year. He permanently closed the main                Recovery
office in Gautier and reopened in a satellite office about               Dr. Glenn Dubroc (New Orleans, LA) offers this
three weeks after Katrina. Many patients were displaced             observation, “Not that it is unbearable, but everything
for months, some relocated, and he never heard from some            about life post-Katrina is more complicated. You must
patients again. His main office is on a list for an appraisal       allot more time to do almost everything – trips to the
which will probably be done by Christmas (2006).                    bank, post office, grocery store. Restaurants and places
     Since any human story is about people, many doctors            of business close much earlier than normal because they
had a concern about the people with whom they work –                still do not have the staff to maintain their pre-Katrina
their staffs. The losses of staff mirrored the losses of doc-

SAO                                                                                                           Fall 2006

hours. It is slowly getting back to ‘normal,’ with the      the area where your service is. Text messaging on the cell
emphasis on slowly.”                                        was the only thing that worked for several weeks.
    On a scale of 1 (still in disarray) to 10 (back to           Dr. Daniel: Being aggressive [in finding a rental
normal), this is how the respondents rated their current    home] and looking early was critical in securing alterna-
situation:                                                  tive housing. It is imperative for orthodontists to have a
0     1     2 3         4     5      6     7     8     9 10 slush fund of money to carry them through emergencies.
                                                            This allowed me to pay my staff at least somewhat and
                                                            cover me through the hard months.
                                                                 Dr. Querens: The term “top shelf ” has a whole new


                                                               Daniel, Mayfield and Whitley

                                                            meaning now. Back up the office computer to a laptop so
                                                            you can access your patients and the internet for informa-
                                                            tion. Get patient cell phones and emails in the data base.
                                                            Place big supply orders after hurricane season.
 Advice                                                          Dr. Dubroc: (1) Back up all computer information. (2)
      Here are the responses when asked “Reviewing your     Do not leave home without your patients’ phone numbers,
 experience of the past year, what tips would you offer     especially cell numbers. (3) Collect email addresses on
 to someone to prepare for an impending natural dis-        EVERY patient. Print out a current list before evacuating
 aster (assume you have 24 hours notice)?”                  and bring it with you. (4) If you keep hard copies of
      Dr. McKinley: Gas up everything that holds gas as     patients’ files, place them in boxes and wrap the boxes in
 soon as possible. Keep a stash of canned goods on hand,    plastic garbage bags. That way, if your office floods or has
 always. Fill up the washing machine, bath tubs, bottles,   rain damage, the charts will stay dry (assuming they don’t
 milk cartons, etc. with water. Charge cell phones, have    float away). (5) Place all insurance policies in one location;
 batteries, etc. Don’t do a lot of driving unless you leave that way they can be gathered up at a moment’s notice.
 the area before the storm. Leave early!                    Bring all insurance policies (especially policy numbers)
      Dr. Nguyen: Pack all your personal belongings and     with you when you evacuate. (6) Video-tape your house
 anything you would want to keep in the future. Store       and all contents. Bring the tape with you when you evacu-
 everything that cannot be replaced in waterproof contain-  ate. [Might be wise to video tape your office too]. (7)
 ers. DON’T rely on your insurance company. They do         Write down all serial numbers for all major appliances.
 not want to pay.                                           Place this with your insurance policies. (8) Have a written
      Dr. Favaloro: Plenty of insurance of all kinds and    evacuation plan (personal and professional). Know exactly
 leave early. Trying to evacuate at the last minute when    what you plan to bring with you and what stays. This will
 about a million other people are trying to do the same is  save brain-power when the emergency strikes.
 self destructive.
      Dr. Whitley: Get Out                                  Conclusion
      Dr. Ballard: Prepare for the worse and be prepared to      Dr. Favaloro said that parts of the city [New Orleans]
 take care of yourself and your family. Do not count on     will take 15 years to rebuild. Some places will never come
 other sources for help. They may be a long time in com-    back. Dr. Nguyen was grateful to be in such a great pro-
 ing. Take anything that is important to you. Everyone      fession with caring people, “Orthodontics is truly a great
 should review their insurance policies thoroughly now and profession.” Dr. McKinley was grateful to be alive and
 have a clear understanding of their coverage.              had a new appreciation of the many blessings in this won-
      Dr. Mayfield: Make sure you have the coverage         derful country. “Many people from far away came to help;
 [insurance] you “think” you have. Take all insurance       a true example of the brotherhood of the American spirit.”
 policies with you. Make sure that you have home tele-           Many thanks to the SAO members who took the time to
 phone numbers as well as cell phone numbers for your       share their experiences after Katrina, et al. Some items
 staff.** Back up your computer and take the disc with      were mentioned several times by different people. This was
 you. Take anything with you that you know you can’t live   a reflection of the importance of the item.
 without. We took our art collection, photographs, and           We know that some members in Florida and Alabama
 important papers. In hindsight, we would have hired a      were affected by Katrina and other hurricanes the previous
 large truck and moved a lot out. However, when a storm     year. We salute all members who have overcome adversity.
 is coming, the rental trucks go fast.
      **Communication is very difficult. There is no power       *The SAO waived dues for all members affected by
 for weeks….no home phones. Cell phones don’t work in       the hurricanes upon request.
Fall 2006                                                                                                                    SAO

Are You Prepared?
    “…the deadly flu epidemic hit the Paradise Hill area. The Milton Township schools were closed for four weeks.
Church services were cancelled for five weeks. Pool rooms, barber shops, drug stores, meat markets and groceries were
closed. The shops remained open, but any employee who contracted the flu had to have a physician’s certificate that they
had recovered before they could go back to work. There were no fatalities in the community, but quite a number…were ill
with the disease.”
                                                                                            Ashland (Ohio) Times Gazette, 1918

          nfortunately, despite the progress of 80 years dur-        demic will occur in the next four years. (The Futurist,
          ing the 20th century, the scenario described above         September-October 2006, page 53) Because of the integra-
          could repeat itself again. As The Futurist maga-           tion of world society through travel and dependence of pro-
 zine says, “people and products now traverse the planet             duction by cheap labor in other parts of the world, the result
 with ease, meaning that a future flu pandemic may engulf            may not be only bothersome, it could be catastrophic.
 the world with unprecedented speed.” (September-October                 Fortunately, there are not many instances of pandemic
 2006, page 55)                                                      events – The Black Plaque of 1347-1351 and the Spanish
      Can we image how a pandemic event would affect                 Flu of 1918-1919, each killing at least 20,000,000 people.
 your practice? Imagine – 20% of your staff would not be             There were lesser pandemic events in 1958 and 1968.
 able to come to work for two weeks. Imagine – 30% of                    The U.S. government estimates that in a moderate pan-
 your patients would not be able to keep or make appoint-            demic event, 90,000,000 would become ill and more than
 ments because they were ill. This could go on for four              half would require medical care with 200,000+ deaths.
 weeks or more. Even if patients were not sick, they would           The government estimates that in a severe pandemic event,
 not want to go out in public where they could be exposed            90,000,000 would become ill and over 10,000,000 would
 to the virus. Imagine – you are unable to replenish your            require hospital care with almost 2,000,000 deaths. Other
 supplies because the supplier cannot produce or ship them.          planning assumptions:
      Orthodontists need to be proactive in planning for an          • There will not be enough vaccine for the entire
 Avian Flu Pandemic. This may be another Y2K event that              population.
 doesn’t happen. But what if it does? In a recent survey,            • Illness rates will be highest among school-aged children.
 56% of U.S. doctors believe that a global influenza pan-            • The population should not depend entirely on the federal

  3. World Health Organization’s (WHO) phases for pandemic influenza
  WHO phases are designed as a system for informing the world of the seriousness of the threat of
  pandemic influenza and to facilitate pandemic planning. The world was in phase 3 as of March 2006:
  a new influenza virus subtype causing disease in humans, but not as yet spreading efficiently and
  sustainably among humans.
   Inter-pandemic phase                         Low risk of human cases                                               1

   New virus in animals, no human case          Higher risk of human cases                                            2

   Pandemic alert                               No or very limited human-to-human transmission                        3

   New virus causes human cases                 Evidence of increased human-to-human transmission                     4
                                                Evidence of significant human-to-human transmission                   5

   Pandemic                                     Efficient and sustained human-to-human transmission

SAO                                                                                                                   Fall 2006

government, but instead work with state and community                " If you don’t already do this, cross-train employees to
governments to be prepared. Business owners must share               do tasks which they do not ordinarily perform.
some of the burden to prepare for a pandemic.                        " Practice new ways to problem solve for unpredictable
     As you can see by the chart on page 14, by Phase 4,             situations, “what if ” scenarios, e.g. what would employees
there is no longer time to plan – it will be time to act.            do if the orthodontist was stricken?
Will you be ready?                                                   " If not already, get involved with a group of orthodon-
     Here are some things orthodontists can be thinking              tists that will cover for you if you are sick for a period of
about if the worst happens. Lesser degrees of this plan              time.
would be useful to your practice in any emergency. ALL
                                                                     " Realize and practice strong leadership traits:
orthodontists could be exposed to legal issues by not tak-
                                                                            # Communicate truthful information to the best of
ing steps to protect employees and patients, e.g. if an
                                                                            your knowledge.
employee becomes infected at work, the employer may
                                                                            # Make good decisions and act quickly.
face penalties under OSHA provisions.
                                                                            # Provide comfort and emphasize the most
" Educate employees about modes of transmission and
                                                                            important function will be the well-being of staff
symptoms. Demonstrate infection control practices.                          and patients.
" Expand personal space to three feet as much as possi-                     # If not already, initiate a communication network
ble. Limit meetings in a confined space and avoid them if                   with staff and patients. Technology will be very
possible.                                                                   helpful with websites and blogs.
" Closely monitor employee health and require that                          # Designate a trusted employee to be available if
employees inform you if they have been exposed.                             you get sick.
" Review office policies and be very clear about when an                  Below is part of a checklist especially designed for
employee with transmissible conditions will be allowed to            orthodontic offices to prepare for a pandemic situation or
return to work. It is estimated that infected people will be         any extreme emergency. The entire checklist can be found
contagious up to two days before symptoms are apparent,              on the SAO website at
ill for 5-8 days, contagious up to seven days when symp-                  Other websites of interest are
toms disappear.                                                      and
" Respect privacy restrictions with personal health infor-                There may not be a pandemic. But if there is, there
mation.                                                              could be wild dislocations of business, commerce, and
" Extend or expand sick leave policy to prevent employ-              travel. Don’t let the situation destroy human cohesion
ees from working while infected.                                     with a level of uncertainly that people will feel that they
                                                                     have lost control.

Communicate to and educate your employees:
Completed In Progress Not Started
                                    Develop and disseminate programs and materials coveringpandemic fundmentals (e.g. signs
  ❏           ❏          ❏          and symptoms of influenza, modes of transmission), personal and family protection and
                                    responses strategies (e.g. hand hygiene, coughing/sneezing, etiquette, contingency plans).

  ❏           ❏          ❏          Anticipate employee fear and anxiety, rumors and misinformation and plan communica-
                                    tions accordingly.

  ❏           ❏          ❏          Ensure that communications are culturally and linguistically appropriate.

  ❏           ❏          ❏          Disseminate information to employees about your pandemic preparedness and response plan.

  ❏           ❏          ❏          Provide information for the at-home care of ill employees and family members.

                                    Develop platforms (e.g. hotlines, dedicated websites) for sommunicaing pandemic status
  ❏           ❏          ❏          and action to employees, vendors, suppliers, and customers inside and outside the worksite
                                    in a consistnet and timely way, including redundancies in the emergency contact system.

  ❏           ❏          ❏          Identify community sources for timely and accurate pandemic information (domestic and
                                    international) and resources for obtaining counter-measures (e.g. vaccines and antivirals).


           by James L. Ackerman, Martin R. Kean and Marc B. Ackerman
           Reprinted with permission from the Australian Orthodontic Journal, Volume 22, No. 1, May 2006

                                                   n this era of the World Wide Web there is
                                                   instant access to a vast store of informa-
                                                   tion related to clinical practice in
                                               orthodontics. Not all of this information is of
                                               equal value, however, creating the need for
                                               standardized and unbiased means of evaluat-
                                               ing it, and for determining the relative merits
                                               of various types of data in clinical practice.
                                               What has emerged from this effort is ‘evi-
                                               dence-based’ medicine and dentistry. By this
                                               measure inferences drawn from expert opin-
                                               ion are considered weak; narrative literature
                                               reviews are accorded moderate value; system-
                                               atic reviews relying on the results of prospec-
                                               tive randomized clinical trials are considered
                    Dr. James Ackerman         strong; and consensus reports based on robust
                                               evidence-based systematic reviews are regard-
           ed as providing the most valid and reliable evidence for determining a course
           of action in clinical practice.1
                Because orthodontics is a latecomer to prospective randomized clinical tri-
           als few truly robust systematic reviews have been published. As a result much
           of clinical orthodontic decision-making is based on case narratives such as
           ‘describe how you would treat a Class II, division 1 malocclusion in a twelve-
           year-old female with no primary teeth remaining’. Against this backdrop the
           present controversy regarding whether the clinical decision-making process in
           orthodontics should be primarily experience-based or evidence based is taking
           place. Academicians and orthodontic journal editors assert that evidence-based
           information ought to be paramount, while many full-time practicing orthodon-
           tists claim that the practical thought processes they apply daily are primarily
           experience-based and rely heavily on case narratives. The debate can be quite
           passionate and as a result the discourse often produces more heat than light.
           This outcome is not only unfortunate, but is entirely unnecessary since it stems
           from the spurious premise that the two positions are mutually exclusive if not
           frankly antagonistic.
                Decision-making in orthodontic clinical practice is based neither wholly on
           evidence nor on experience. Rather it is firmly based on a type of practical rea-
           soning called clinical judgement. Opponents in the current debate would readi-
           ly agree that the hallmark of a good orthodontist is the ability to exercise sound
           clinical judgement. This core competency incorporates application of experi-
           ence and consideration of evidence, complementary qualities compatible in,
           and necessary for, interpretative reasoning. In her recent monograph, “How
           Doctors Think,”2 Kathryn Montgomery holds that clinical judgement embodies
           the capacity for rational thinking and action in the face of uncertainty. It is the
SAO                                                                                                                    Fall 2006

educated hunch required when there is little formal evi-             ing the pejorative term ‘anecdotal’ when referring to any
dence to be applied, yet an opinion or action is needed to           clinical opinion or action that cannot be supported by pub-
decide the best course of action to be taken for the                 lished scientific evidence. ‘Narrative’ and ‘anecdotal’ are
patient. Clinical judgement is needed to decide what is              tantamount to the same thing. EBOs bristle when an
optimal for that individual at the time when the only                accomplished clinician makes a statement prefaced by ‘in
available evidence is derived from averages. It is percep-           my experience’ as if sacrilege had been uttered. The EBO
tion based on experience with sometimes little immediate             implication is that orthodontics is now a science when, in
scientific evidence to support it. Scientific evidence alone         fact, orthodontics in itself is clearly not a science although
may reduce, but not eliminate, uncertainty when making               it relies more and more heavily on science and technology.
clinical decisions or predicting outcomes, but reflective            The need for greater use of scientific evidence in clinical
clinical judgement honed by experience makes a unique                orthodontics is not in dispute here. But to denigrate the
and necessary contribution to clinical decision-making.              contribution of experience and the narrative case-based
     In orthodontic practice clinical judgement requires a           tradition in our specialty is an injustice to the truth. The
similar integration of clinical experience and systematic            truth is that the most important attribute of a thoroughly
assessment of relevant scientific evidence in the context            competent clinician is clinical judgement, which develops
of the patient’s orthodontic condition, treatment needs and          from sound experience and is bolstered by, but not based
preferences. Clinical judgment is                                                            exclusively on, systematic scientific
indeed a skill or a ‘knack’ (art),                                                           evidence.
incorporating the best available                                                                  In dentistry orthodontic prac-
evidence (science) with societal          Decision-making in                                 tice is unique in the time it takes to
and patient values and tastes                                                                complete one unit of clinical expe-
(trans-science). Some elements of         orthodontic clinical                               rience, that is, the management of a
orthodontics transcend the realm                                                             patient, from first contact to com-
of science to extend into exercising   practice is based neither                             pletion and follow-up. During this
moral or aesthetic judgments. In                                                             time, and the years that follow
this sphere there may be questions     wholly on evidence nor                                treating other patients, a clinician
to be asked in scientific fashion                                                            gains experience that contributes to
but not open to testing in a scien-    on experience. Rather it                              and enriches continuously his or
tific manner.                                                                                her clinical judgement, that unique
     These issues have been called       is firmly based on a                                competency which is the hallmark
trans-scientific.3 Robust scientific                                                         of the truly accomplished clinician.
evidence in the life sciences           type of practical rea-                               Orthodontists cannot realistically
aspires to a level of reliability and                                                        aspire to practice in an entirely evi-
predictability possible many times       soning called clinical                              dence-based mode. We have a
only in the physical sciences                                                                proud heritage of contributing sig-
because of the variability inherent            judgement.                                    nificantly to the lives of the vast
in biological systems.                                                                       majority of our patients. Therefore,
     Orthodontists admire the relia-                                                         let us put aside an empty debate
bility and predictability offered by strong scientific evi-          and agree that the soundest mode of practice today is r
dence. It is unlikely that any group craves control more             reflectiv eflective, experienced evidence-bolstered
than orthodontists. If it is agreed that clinical judgment is        orthodontics.
a critical virtue for an orthodontist, and orthodontists
acknowledge the reliability of valid scientific evidence,            Dr. Ackerman can be reached at Jim Ackerman; 1030 Fearring-
why should there be dispute regarding the relative value             ton Post; Pittsboro, NC 27312, email:
of experience versus evidence in orthodontic diagnosis
and treatment since each is a key element of clinical judg-
                                                                     1. Huang GJ. Bigfoot lives? Am J Orthod Dentofacial Orthope-
ment? There may be some disinclined to be ‘inclined con-
                                                                     dics 2006;129:323–4.
fused with the facts.’ On the other hand, adherents of               2. Montgomery K. How Doctors Think. 2006, Oxford University
evidence-based orthodontics (EBOs) in recent years have              Press. New York.
been extremely critical of the value of narrative case-              3. Ackerman JL. Orthodontics: Art, science or trans-science?
based and experience-based orthodontic practice, apply-              Angle Orthod 1974;44:243–250.

Fall 2006                                                                                                                    SAO

 Craniofacial Dynamics Explored
 by Jorge C. Coro, DMD, MS                                                 By alleviating the posterior discrepancy and
                                                                      “reconstructing” the occlusal plane (tipping it down in

         r. Sadao Sato was the featured speaker at the Flori-
                                                                      front), Class III cases can be treated with excellent, stable
         da Association of Orthodontists’ annual session in
                                                                      results. Open Bites are treated by reconstructing both max-
         March 2006. Dr. Sato is Professor and Chairman
                                                                      illary and mandibular occlusal planes.
 of Orthodontics at Kanagawa Dental College in Japan. He
                                                                           The first example is that of a 12 year, 9 month old
 presented his philosophy of Craniofacial Dynamics and
                                                                      female with a chief complaint of “underbite.” She present-
 spoke on the etiology and treatment of the different maloc-
                                                                      ed a Class III dental relationship with a 3mm midline dis-
 clusions. He explained his ideas on how the antero-poste-
 rior position of the mandible is determined by the vertical
 position and inclination of the maxillary occlusal plane. By
 careful control of the occlusal plane(s) with the use of the
 MEAW (Multiloop Edgewise Arch Wire) technique, he
 demonstrated how severe (skeletal) malocclusions are rou-

                                                                                       Fig. 2 - Case 1, Initial Records

Fig. 1 - Treatment of Class III open bite with the MEAW Technique
                                                                            Fig. 3 - Case 1, Treatment with the MEAW technique
 tinely treated without the need for orthognathic surgery.
      Skeletal Class III and Open Bite malocclusions tend to
 exhibit flexion of the Cranial Base. This flexion produces
 a deficient antero-posterior dimension of the maxilla
 which causes posterior (dento-alveolar) discrepancy. Not
 having sufficient space, the developing molars are essen-
 tially “squeezed out,” resulting in excessive vertical devel-
 opment of the posterior maxilla. This in turn causes a
 flattening (down in back) of the occlusal plane. The
 mandible adapts to the increased vertical height of the
 molars through anterior rotation, resulting in a protrusive
 (prognathic) displacement. In cases where there is weak
 perioral musculature (mouthbreathers), the mandible can-
 not adapt anteriorly and tends to rotate down and back
 resulting in an openbite.
                                                                                       Fig. 3 - Case 1, Final Records
SAO                                                                                                                Fall 2006

crepancy and anterior crossbite. The Cephalometric Anal-
ysis revealed a skeletal high angle Class III relationship.
Note the “flat” occlusal plane.
     The treatment objectives were to eliminate the poste-
rior discrepancy and to steepen the occlusal plane with
the use of the MEAW technique. Attaining the “dynamic
harmony of the craniofacial skeleton” is obtained by the
“reconstruction of the occlusal plane.”
     When the Cranial Base is in the extension position,
Skeletal Class II, the maxilla usually grows due to its pro-
trusive rotation and displacement. This results in exces-
sive antero-posterior development and insufficient dental
eruption in the molar areas. This in turn leads to defi-
cient posterior vertical development of the posterior max-
illary alveolar process and insufficient dental eruption.                  Fig. 6 - Case 2, Final Records
This results in a steep occlusal plane (down in front)
which inhibits the mandible’s ability to adapt anteriorly.
The mandible then assumes a retrognathic position.
     The second example is that of a 30-year-old male
who presented with a chief complaint of dental protru-
sion. He exhibits a dental Class II with a moderate over-
bite and severe overjet. The mandibular first premolars
are blocked out lingually. The cephalometric analysis
revealed a skeletal low angle Class II relationship. Note
the steep posterior occlusal plane.
     The treatment objectives were to increase the vertical
dimension, flatten the posterior occlusal plane and obtain
anterior mandibular reposition. These objectives were
obtained and the case was successfully treated with the
use of the MEAW technique.
     Dr. Sato’s treatment philosophy is based on his exten-
sive research and a novel interpretation of studies found             Fig. 7 - Case 2 - Six years post treatment
                        Craniofacial continues on page 27

                                                                    Fig. 8 - Pre, post and six years after treatment

                Fig. 5 - Case 2, Initial Records


               The SAO News includes an ABO case report in each issue. These case reports
               are published exactly as they were presented to the American Board in order to
               give the aspiring candidate an example of how case reports are prepared and
               presented to the American Board of Orthodontics.
                James A. High, DDS
                The case report was presented to the American Board of
                Orthodontics during the 2006 Phase III examination in
                partial fulfillment of the requirements for the recertification
                process conducted by the Board.

               PATIENT’S NAME: Rhea Miller
               DATE OF BIRTH: 06/11/ 1987
               AGE: 15 years, 3 months
                                                                                  James A. High, DDS
               A.      PRETREATMENT RECORDS
                       Date of Records: 09/04/2002
               • Skeletal: Severe skeletal Class III with mandibular prognathisnm, maxillary
               retrusion & maxillary constriction
               • Dental: Class III
               • Facial: Mandibular prognathism and maxillary retrusion

               Treatment Plan:
               1. Rapid expansion of the maxillary midpalatal suture
               2. Band and bond upper and lower arches
               3. Coordinate upper and lower arches for orthognathic surgery
               4. Maxillary advancement and mandibular set back
               5. Post surgical orthodontics to finish and detail
               6. Retention

               • Initiated Treatment Date: RPE 10/16/02 Fixed edgewise 05/15/03
               • Appliance Removal Date: 12/30/2004
               • Active Treatment Time      Duration: 26 months

               B.       POSTTREATMENT RECORDS
                        Date of Records: 12/30/04
               Retention: Fixed maxillary 1-1, fixed mandibular 3-3, maxillary hawley
               • Retention Completed           Date: ongoing
               • Retention                     Duration: indefinite

               HISTORY AND ETIOLOGY:
               Medical: The patient is a well nourished 15y, 3m old postmenarchal,
               Caucasian female with a history of normal childhood diseases
               Dental: Overall dental health within normal limits; fair oral hygiene; receives
               regular dental care
               Etiology: No familial history of congenital jaw deformities of this type

SAO                                                                                                             Fall 2006

    Profile Relaxed            Frontal Relaxed           Frontal Smiling
                                                                                          Lateral Cephalogram

           Right Buccal                             Frontal Dental                             Left Buccal

                                                                  PRETREATMENT SERIES

                                                                  3. Band and bond 6-6 in maxilla and 7-7 in mandible
                                                                  4. Presurgical coordination of upper and lower arches
                                                                  5. Orthognathic surgery to advance maxilla and set back
                                                                  6. Post surgical orthodontics to finish and detail
                                                                  7. Interarch elastics as needed
                                                                  8. Retention
                          Panorex                                 SPECIFIC OBJECTIVES OF TREATMENT:
                                                                     • A-P: Advance maxilla
Skeletal: Class III with mandibular prognathism and max-
illary retrognathia and constriction
                                                                     • A-P: Set back mandible
Dental: Class III molar and cuspid relationship
                                                                     • Vertical: Maintain
         Mild mandibular crowding
                                                                  Maxillary Dentition
         Retroclined lower incisors
                                                                     • A-P: Maintain
         Four millimeters of negative overjet
                                                                     • Vertical: Minimize extrusion
         Canted occlusial plane
                                                                     • Intermolar Width: Expand to accommodate
         Bolton’s Analysis not significant
         Buccal segments in crossbite
                                                                     • Used mesiolingual cusp tips as landmarks for
                                                                     intermolar width 6-6
                                                                  Mandibular Dentition
1. Rapid expansion of the maxillary mid-palatal suture
                                                                     • A-P: Procline lower incisors
2. After six months of stabilization and retention, place-
                                                                     • Vertical: Minimize extrusion
ment of palatal bar 6-6 in maxilla

Fall 2006                                                                                                           SAO

    Profile Relaxed             Frontal Relaxed        Frontal Smiling
                                                                                         Lateral Cephalogram

            Right Buccal                          Frontal Dental                              Left Buccal

                                                           Upper Occlusal                        Lower Occlusal
                                                                                            POST TREATMENT SERIES
    • Intermolar/Intercanine Width: Slightly increase to                                           12/30/04
    round out arch                                              4.  Twelve millimeter hyrax appliance placed
    • Used mesiolingual cusp tips as landmarks for              5.  Forty turns (10 mm) of sutural expansion appliance
    intermolar width 6-6                                        6.  Six months of retention with expansion appliance
    • Used cusp tips of 3-3 as landmarks for intercuspid        7.  Palatal bar 6-6 in maxilla; 5-5 upper and 7-7 lower
    width                                                               edgewise bonds placed; .015 U & L AWs
Facial Esthetics                                                8. Progressed to .018x.025 UAW and .016x.022 LAW
    Improve overall facial appearance                           9. Extraction of all third molars
                                                                10. Coordination of upper and lower arches
APPLIANCES: 12mm OIS Hyrax appliance for sutural                11. Orthognathic surgery consisting of a maxillary
expansion                                                           LeFort I osteotomy with maxillary advancement and
.022 X .028 American edgewise appliance                             posterior intrusion: mandibular surgery was a setback
TREATMENT PROGRESS:                                                 utilizing vertical subcondylar osteotomies; a decision
1. Diagnostic records                                               concerning the need for a vertical reduction
2. Consult with patient and parents                                 genioplasty will be made at a later date
3. Patient and parent consult with oral surgeon                 12. Post surgical orthodontics to finish and detail the

SAO                                                                                                                  Fall 2006

    case utilizing a Class III elastic on the patient’s right        RETENTION: Fixed lingual retainers 1-1 maxilla and
    side, a Class II elastic on the patients left side, and a        3-3 mandible; maxillary Hawley retainer
    midline elastic from the upper right cuspid to the
    lower left cuspid; these elastics were worn for four             FINAL EVALUATION OF TREATMENT:
    months                                                           The patient’s malocclusion was improved during treat-
13. Finishing wires were .019x.025 TMA in the upper                  ment. The skeletal disharmony that existed prior to thera-
    arch and .016x.022 in the lower arch                             py was partially resolved. A functional, mutually
14. Deband and debond                                                protected occlusion was established. A slight increase in
15. Fixed lingual retainers 3-3 lower and 1-1 upper;                 normal overjet and normal overbite was noted. There is a
    maxillary Hawley retainer                                        slight Curve of Spee remaining which if completely lev-
                                                                     eled would have made the overbite/overjet relationship
RESULTS ACHIEVED:                                                    ideal. This would have also increased the proclination of
Maxilla                                                              the lower incisors. Due to the preexisting Class III rela-
  • A-P: Slight advancement obtained through LeFort I                tionship and open bite tendency, some relapse would be
  osteotomy                                                          expected with time to improve the overbite/overjet rela-
Mandible                                                             tionship. Settling in the second molar areas should provide
  • A-P: Set back obtained through vertical subcondylar              for occlusion of these teeth. Good alignment was obtained
  osteotomies                                                        in both the maxillary and mandibular arches. Slight
  • Vertical: Slight increase                                        marginal ridge discrepancies were seen between the maxil-
Maxillary Dentition                                                  lary left permanent first molar and the maxillary left sec-
  • A-P: Maintained                                                  ond bicuspid. A small marginal ridge discrepancy was
  • Vertical: Maintained                                             also noted between the lower right permanent first molar
  • Intermolar Width: Increased 5.5mm                                and the lower right second bicuspid. The maxillary and
Mandibular Dentition                                                 mandibular midlines are coincidental with the facial mid-
  • A-P: Lower incisors proclined a small amount                     line. The patient’s third molars were removed prior to
  • Vertical: Maintained                                             orthognathic surgery. A pleasing smile with improved
  • Intermolar/Intercanine Width: increased 3.0mm/                   facial esthetics was noted. The profile was greatly
  increased 0.5mm                                                    improved with better facial harmony and balance.
  • Facial Esthetics: Overall facial harmony and
  balance improved

 Dallas Margeson, DDS
 The case report was presented to the American Board of Orthodontics during the 2006 Phase III examina-
 tion in partial fulfillment of the requirements for the certification process conducted by the Board.

PATIENT’S NAME: Eric Jefferson                                   and mandibular arch length deficiency. All second premo-
DATE OF BIRTH: 12-25-1975                                        lars are severely rotated. The midline was 4mm left of
AGE: 26 years                                                    center. The LL3 is buccally displaced. The patient has
                                                                 minimal overbite and there is moderate bone loss around
A.      PRETREATMENT RECORDS                                     the LL7.
        Date of Records: 1-8-2002
                                                                 • Facial: Lips protrusive to E-line with a bimaxillary pro-
Diagnosis:                                                       trusion.
• Skeletal: Class II skeletal relationship with a large api-
cal base discrepancy (ANB of 11°); maxillary and                 Treatment Plan: 1) Root plane lower left posterior quad-
mandibular incisors are protrusive (1 to SN of 102° and a        rant. 2) Reduce protrusion (upright incisors). 3) Extract
1 to Go-Gn of 107°).                                             the maxillary and mandibular first premolars. 4) Resolve
• Dental: Class I malocclusion with a severe maxillary           severe crowding. 5) Establish proper overbite. 6) Center

Fall 2006                                                                                                                SAO

midlines. 7) Correct rotation on the second premolars. 8)         10) Leave the lingual cusp of the upper 5’s to the facial.
Leave the lingual cusp of the maxillary second premolars          11) Finish and detail. 12) Deband and retain. 13) Extrac-
to the facial. 9) Finish and detail. 10) Deband and retain        tion of 3rd molars post-treatment.
11) Extraction of 3rd molars post-treatment.
                                                                  SPECIFIC OBJECTIVES OF TREATMENT
Treatment: 1) Root plane and cleaning pre-treatment.              Maxilla
2) Full .022 fixed edgewise appliances. 3) Extraction of          • A-P: Maintain or retract
first premolars. 4) Level and align. 5) Position UR2, LL3,        Mandible
and R & L 5’s. 6) Center midlines. 7) Reduce protrusion.          • A-P: Maintain
8) Close extraction space using intra-arch elastics. 9)           • Vertical: Maintain (decrease)
Establish proper overbite and overjet. 10) Equilibrate            Maxillary Dentition
lingual and buccal cusps of the upper 5’s. 11) Finish and         • A-P: Reduce incisor protrusion
detail. 12) Deband and retain.                                    • Vertical: Maintain
                                                                  • Intermolar Width: Maintain
Initiated Treatment   Date: 01-14-02                              Mandibular Dentition
Appliance Removal     Date: 06-08-05                              • A-P: Reduce incisor protrusion
Active Treatment Time Duration:    29 months                      • Vertical: Maintain
                                                                  • Intermolar / Intercanine Width: Maintain
B.      POSTTREATMENT RECORDS                                     Facial Esthetics
        Date of Records:      06-08-05                            • Reduce protrusion
        Retention:     a) Maxillary Essix
                       b) Mandibular bonded 3-3                   APPLIANCES: .022 Straightwire edgewise appliances

Retention Completed     Date:           ongoing                   TREATMENT PROGRESS:
Retention               Duration:       lifetime                  The Patient got a cleaning and root planning pre-treat-
                                                                  ment. On 01-14-02, full .022 edgewise appliances were
HISTORY AND ETIOLOGY:                                             placed. He was referred for extraction of the four first
The patient is a 26-year-old African-American male with           premolars; round nickel titanium wires were used to level
a chief concern of “Perfect my smile; even my teeth;              and align. A button was placed on the lingual LR5 to de-
remove teeth grown out of position and line the top with          rotate. Equilibration was performed on the lingual and
the bottom.” The etiology is believed to be heredity. His         buccal cusps of the U5’s (actually left the lingual cusps to
medical history is unremarkable.                                  the buccal). A progress pan was obtained and the roots
                                                                  were evaluated for parallelism and the lower left posterior
DIAGNOSIS:                                                        quadrant was evaluated. Worked up to U/L 19x25 SS and
Skeletal: Class II skeletal relationship with an ANB1 of          used intra-arch elastics to close extraction spaces and
11°; maxillary and mandibular incisors are protrusive             maintain torque. Finished in an upper 19x25ss and lower
(1 to SN of 102° and a 1 to Go-Gn of 107°).                       19x25TMA. Some Class II elastics were used during
                                                                  space closure. He was debanded and retained and
Dental: Class I malocclusion with a severe maxillary and          referred for extraction of his third molars. He has not
mandibular arch length deficiency. All second premolars           returned to our office since his deband appointment.
are severely rotated. The midline was 4mm left of center.
The LL3 is buccally displaced. He has minimal overbite            RESULTS ACHIEVED:
and there is moderate bone loss around the mandibular             Maxilla
left second molars.                                               • A-P: Maintained ; slightly reduced
TREATMENT PLAN:                                                   • A-P: Maintained
Treatment: 1) Root plane and cleaning pre-treatment. 2)           • Vertical: Maintained
Full .022 edgewise appliances. 3) Extraction of UL 4’s.           Maxillary Dentition
4) Reduce protrusion (upright incisors). 5) Resolve               • A-P: Reduced; uprighted incisors-U1 SN 102° to 88°,
severe crowding. 6) Establish proper overbite. 7) Center          The upper 6’s moved mesial
midlines. 8) Position LL3. 9) Correct rotation of the 5’s.        • Vertical: Maintained
SAO                                                                                                   Fall 2006

      Profile Relaxed             Frontal Relaxed         Frontal Smiling
                                                                                   Lateral Cephalogram

      Right Buccal                Frontal Dental          Left Buccal

                                                                                    Lateral Tracing

       Upper Occlusal                    Lower Occlusal

           Right                            Frontal                         Left

                                                                                   PRETREATMENT SERIES

Fall 2006                                                                                                                          SAO

        Profile Relaxed             Frontal Relaxed    Frontal Smiling                          Lateral Cephalogram

      Right Buccal             Frontal Dental              Left Buccal
                                                                                             Lateral Tracing

            Right                     Frontal                Left

                                                                                                 Final Superimpositions
                                                                    Cephalometric Summary

                                                                     AREA               Measurement         A1     B        *Diff.
                                                                    Maxilla to
                                                                    Cranial Base                   SNA       81        80      1
       Upper Occlusal               Lower Occlusal                  Mandible to                 SNB          70        70      0
                                                                    Cranial Base            SN-Go-Gn         50        49      1
                                                                                                FMA          33        35      2
                                                                                                   ANB       11        10      1
                                                                    Maxillary           1 to NA (mm)        5mm    .5mm     4.5mm
                                                                    Dentition                 1 to SN        102       88     14
                                                                                      6-6 (mm)(casts)       47mm   44mm      3mm
                                                                    Mandibular          1 toNB (mm) 22 mm 16mm
                                                                    Dentition                               92                15
                                                                                           1 to Go-Gn 107
                                                                                                           40mm              0mm
                                                                                      6-6 (mm)(casts) 40mm
                                                                                      3-3 (mm)(casts) 28mm 28mm              0mm

                          Panorex                                   Soft Tissue         Esthetic Plane 12mm        3mm       8mm

                                                                    A1 Pretreatment records
                   06/08/05                                         A2 Interim or progress records if indicated
                                                                    B Posttreatment records
SAO                                                                                                                  Fall 2006

• Intermolar Width: Maintained
Mandibular Dentition                                               Craniofacial Continued from page 19
• A-P: Reduced; uprighted incisors- L1 GoGn 107° to
92°, The lower 6’s moved mesial
• Vertical: Maintained
• Intermolar/Intercanine Width: Maintained
Facial Esthetics
• Reduced protrusion. There was a significant reduction
as evidenced by the E-line.

RETENTION:                                                           Fig. 9 - Case 2 - Adaptation to the new occlusal scheme to
Upon completion of active treatment, a maxillary essix                          produce favorable changes with time.
retainer was placed and a lingual retainer was bonded to
                                                               in the existing literature. In addition to conventional
the lower 3-3. He was instructed to wear his removable
                                                               orthodontic records, his excellent clinical results are
retainer full time for 3 months and then at night.
                                                               documented with the use of computerized axiography to
                                                               record pre and post condylar position.
Treatment was successful. I was able to position his U5’s
                                                                    The numerous examples of his treated cases, many with
(buccal cusp in lingual cusp position) and provide a satis-
                                                               long term follow up, show us what is possible with the
factory interdigitation with the help of equilibration. My
                                                               MEAW technique when his principles of occlusal plane con-
satisfied goals were: resolve the crowding, reduce the
                                                               trol are followed. Dr. Sato is currently spreading his ideas
protrusion, upright incisors, center midlines and position
                                                               throughout Europe, teaching comprehensive courses in
LL3. He has never returned for a retainer check and he
                                                               Hamburg, Frankfort, and Vienna.
has not had his third molars removed. The prognosis for
stability is good with proper retainer wear. After critical
assessment using ABO standards the patient needed more
lingual root torque on LL3 to upright the tooth. This
affected the interdigitation of the left cuspids.

                                    2007 SAO Calendar
JANUARY                                                        MAY
12    SAO Leadership Development Program, Atlanta              18-22 AAO Meeting, Seattle, WA
13    SAO Executive Committee, Atlanta
28-31 AAO Leadership and Government                            JUNE
      Affairs Conference, Washington DC                        10       MAO Meeting, Destin, FL
                                                               15       ALAO Meeting, Perdido Beach, AL
FEBRUARY                                                                Speaker: Dr. John Graham
2-3   NCAO Meeting, Research Triangle Park, NC                 30       VAO Meeting, (continued), Virginia Beach, VA
      Speakers: Charlene White (FR) and John McGill (SA)
9     TAO Meeting, Franklin, TN                                JULY
      Speaker: Dr. Jimmy Boley                                 1-2      VAO Meeting (continued), Virginia Beach, VA
16-17 GAO Meeting, Ritz Carlton, Lake Oconee, GA               21       WVAO Meeting, Greenbrier, WV
      Speaker: Dr. Rolf Behrents
MARCH                                                          14    KAO Meeting, Lexington, KY
2-4   FAO Meeting, Tampa, FL
      Speakers: Drs. Robert Boyd, Tim Wheeler,                 OCTOBER
      Clark Colville, David Paquette                           31    SAO Meeting (continued), Westin Diplomat
9     SAO Leadership Development Program, Atlanta                    Hollywood, FL
10    SAO Board of Directors Meeting, Atlanta                  November
23-24 SCAO Meeting, Charleston, SC                             1-4   SAO Meeting (continued)
      Speaker: Bruce Manchion                                        Westin Diplomat, Hollywood, FL


               Collection Processing in the
Staff Corner   New Millenia
               by Brenda Cooper-Vogeley

                        rthodontic practices have progressed in many ways in the last 25 years.
                        One way that some practices have changed is in the collection of fees.
                        A legacy of the past is that all too often, orthodontists are in the collec-
               tion business. There are several reasons why this may not be a good idea: first,
               the general public sometimes feels the need to pay their orthodontist ONLY
               when they have an appointment. This is a misconception as we all know. It is
               our job to educate the patient and set the ground rules at their initial visit. Sec-
               ond, many orthodontic offices are faced with delinquency rates running 30, 60,
               or 90 days. Third, orthodontic practices that accept insurance endure an ongo-
               ing fight for benefits with insurance companies.
                    The collection process has evolved over time, going from long paper trails
               (peg board and ledger cards) to computerized ledgers and paperless offices.
               Twenty-five years ago patients were paying monthly payments each time they
               came into the office, while being documented onto handwritten ledger cards.
               Insurance claims were also handwritten and mailed to insurance companies,
               taking eight weeks or longer to receive any benefits or explanation of benefits
                    In the 1980’s, computers came along, allowing us to send patients comput-
               erized coupon books, along with a computerized ledger system that did all the
               calculating on the accounts for us. We also had the capability to print and mail
               insurance claims automatically.
                    In the 1990’s, fiber optic technology allowed computers to talk to each
               other via the phone line. This gave us the opportunity to transmit insurance
               claims electronically to clearinghouses, which printed out the insurance claims
               and mailed claims or electronically sent them to the insurance companies.
               Insurance clearing houses reduced response time on claims to four-six weeks.
               We also had, and still have, the ability to transmit electronic statements month-
               ly to patients the same way insurance claims are transmitted. These companies
               are designed to receive the information via phone line or internet transmission
               and then mail the statements to the patients, giving them the option to mail
               payments to offices either by check or credit card. Next came the “World Wide
               Web” (internet).
                    This opened up unimaginable opportunities for the world, not to mention
               the orthodontic community. We now have Web sites with the capability of
               accepting payment by credit card via those Web sites. New software now
               allows offices to process credit cards quicker and to file insurance claims
               directly with the insurance company through their Web sites, receiving benefits
               (payments) anywhere from one to three weeks.
                    Drs. Dunn & Savastano’s practice is located in a large population area
               made up of people in the service and tourism industry, as well as, many profes-
               sionals. Our patient population is representative of incomes that range from
               below the national average to well over six figures. When taking over as finan-
               cial coordinator in the year 2000; (after being a chair side assistant and treat-
               ment coordinator the previous 14 years), I was faced with 100+ patients each

SAO                                                                                                              Fall 2006

month that were past due on their accounts. The constant       merchant, we found credit card processing software
struggle to collect past due accounts was both time con-       designed for re-occurring billing at a competitive rate. The
suming for me and humiliating for the patient. This was        software we use is PC Charge Pro Software (the software
not the best practice builder to say the least.                does not offer the rates, the software is just a user-friendly
     Orthodontists should be reminded, “We are essentially     tool that allows you to set up the re-occurring billing and
providing the patient with an interest free loan. Why can’t    makes it very simple to process. You must search out the
we stipulate how this is paid to our office?” My employers credit card merchants. We use Merchant e-Solutions which
agreed to develop and implement an automated payment           we found through Discover Financial Business Solutions.)
system for our in-house financing without any additional       It’s simple. The software notifies the office that there are
cost to the patient and minimal expense to the practice        transactions to process and, with a click of the button, all
There are no more coupon books, no more monthly pay-           of my accounts process within two minutes. Now, we took
ments paid in the office when the                                                      an already remarkably successful
patient comes in for appointments,              There are no more coupon               automatic payment system and
and no more long lists of 30-, 60-, 90-                                                turned it into an efficient well-oiled
day delinquent accounts. Our delin-              books, no more monthly                machine. The fees we were paying
quencies dropped down to a mere 1%.                                                    by hand-keying credit card (not
This technique may not be for every             payments paid in the office            swiping, card not present) at the
practice or every patient, but we have       when the patient comes in for highest rate of 2.89% vs. 2.18%
had tremendous success with it in our                                                  (card swiped, present). With the
practice.                                       appointments, and no more              software we have a rate of 2.35% on
     This type of payment process is                                                   each transaction processed. In the
highly adaptable to any income level.       long lists of 30-, 60-, or 90-day first year, our credit card fees had
A secured credit card or voided check                                                  gone from $24,000 per year to
on file, allows us to set up payments              delinquent accounts.                $12,000 per year. Not only did our
monthly, quarterly, bi-weekly, annual-          Our delinquencies dropped              automatic payment system turn out
ly, etc. It also allows for special cir-                                               to save us time and money by taking
cumstances, such as split payments in              down to a mere 1%.                  the “collection” process out of the
divorced cases. Because the technique                                                  equation, we have now taken it one
is secure, we can allow patients from divorced families to     step further and found an even more cost effective way to
set up separate ledgers and collect payment from all parties process them. Sound expensive? It really isn’t. Remem-
involved. From a marketing standpoint, it’s a great advan-     ber, your financial coordinator has less than 1% of patient
tage.                                                          delinquencies to deal with and a lot more time to put her
     This collection process can be set up through one of      energies into performing other tasks.
several companies. We prefer Vanco Services LLC as this             By implementing an automatic system, you have basi-
company gives us the ability to pull money from one            cally taken the “collect” out of collections. You are now in
account to another. This is an online financial institution    control of your accounts instead of the accounts in control
that can be managed 24 hours a day, 7 days a week through of you. There are several companies out there that offer
a secure, internet site that will process ACH (electronic      automatic processing. The differences are not that great.
drafts) payments for a nominal fee of $.25 per transaction.    But, keep in mind that you are paying for the same service
We have yet to find a company or bank to beat this. It         you can set up yourself at a less expensive rate. You can
works within the banking system by pulling the set dollar      save your practice money by managing the accounts in-
amount that was agreed upon, from the patient’s checking       house.
or savings account into the office bank account within              If an automatic payment is returned “NSF,” simply go
minutes. The cost of this service is a mere $1,500 per year online and reprocess it as you would if it were a paper
on a $2 million dollar practice. That is far less than what it check. Our office may have two patients out of 400
would cost the office to do the same work.                     accounts that we process each month that come back
     We also give patients the traditional choice of automat- “NSF.” Rarely does it require any more action besides
ically charging a credit card on the first of each month.      reprocessing the payment. The same is true with declined
However, after spending eight hours a month hand keying        credit cards. In researching other companies, you will be
200 cards in the credit card terminal at the front desk, not   paying all the fees mentioned in the in-house system, as
to mention, paying the highest percentage possible to our      well as, the service fees the practice will incur each month

Fall 2006                                                                                                              SAO

 in addition.                                                    pletion date. There are many advantages to this, but most
      My employers feel secure with the fact that I know         importantly you avoid a collection problem at the very end
 what is going on with our accounts at all times. I can          of treatment.) We do accept insurance assignment and set
 always accurately answer our patients’ questions without        payment options based on the patient’s portion of the total
 delay. Our office doesn’t like the thought of relying on        treatment fee.
 another company to process our accounts, not knowing the             You should always advise the patient that only one dis-
 accuracy, as well as, the possibility of not being able to      count applies. We give them the option to choose the dis-
 answer patients’ questions with confidence. By keeping          count they prefer. Usually our family discount would be
 the processing of accounts within the office, we are able to    the better value. When a family discount applies, a pay-in-
 quickly take care of problems that arise. There is no time      full discount is not added in. This never seems to discour-
 spent going between a third party to research answers to        age the patient from paying in full, if that is what they
 patient’s questions or concerns. This way we can provide        want to do.
 good customer service, as well as, customer care in a                Even insurance companies are catching on. They are
 world that tolerates lack of service from other sectors.        trying to become more efficient by providing more inter-
      Once this system is implemented into your office, you      net services for specialists. For example, access Metlife
 will need to be flexible. It is a process. Remember, you        online, go to their Web site to sign up, (you do not have to
 have approximately two years of existing patients that will     be a Metlife provider to use this service) at www.metden-
 still need to payout through your old system. Unless they Be sure you are enrolling for the “free” claims
 opt to change their payment process your new patients will      filing. You can simply begin filing all of your Metlife
 start under the new program. Impress upon patients the          claims online via the internet. The turn around from the
 convenience this will bring them. Most companies have           time you submit the claim and you receive your first pay-
 brochures that can be displayed to peak the interest of your    ment, which is the appliance fee, is seven days. Talk about
 existing patients. You definitely want to emphasize the         service! It is so quick and simple. It literally takes two
 benefits of the automatic payment process. Your life will       minutes to enter and submit the claim. They do not
 become easier and you will start to see the benefits almost     require a treatment plan. You can also verify benefits for
 from the beginning.                                             Metlife on their Web site in a matter of minutes as well.
      You will still find a small percentage of patients who     All the information you need is right there: orthodontic
 request coupon books or paying when they come in for            lifetime maximum, deductibles, if any benefits have been
 appointments. However, you must remember this is not a          used, age limits, how they pay out benefits, etc.
 surprise that has been sprung on them. You have prepared             The goal of this article was to provide the readers with
 them at the new patient exam on how in-house financing          some food for thought. There are obviously many meth-
 is set up, not to mention, you want to reiterate to them        ods for making any orthodontic practice financially stable.
 how your doctor is providing them with an interest-free         This is one way of achieving easier collections. Hopefully
 loan. Your staff will need to be able to consistently recite    this information is of value to many of you. There is cer-
 the same phrases. Scripting is very important (It’s all in      tainly the possibility of combining this new idea with
 how it is said and presented to the patient/parent.). Your      existing methods depending on the patient at hand.
 staff must come across with a unified front.
      Remember, the patient has three options. Your first        You can contact Brenda at
 option should be an outside finance company that will not
 require a down payment and can spread payments out past
 the treatment time. You should have a pay-in-full option
 with some sort of incentive such as a 2 to 4% discount.
 The third option is in-house financing. This is presented
 as an interest-free loan. We provide a loan with 30% down
 to cover our appliance fee, then the balance is spread out
 over a portion of the treatment time, which is automatical-
 ly deducted from a checking/savings account or charged to
 a credit card. (Ideally you would like your monthly pay-
 ments to end two to four months shy of the estimated com-

2006 Annual Meeting Schedule
Wednesday, October 25
8:00 a.m.-5:00 p.m.     Board of Directors Meeting

Thursday, October 26
8:00 a.m.               Golf Tournament
12:30-3:00 p.m.         (D) Dr. William Harrell
                        The Use of 3D Imaging in Private Orthodontic Practice
1:00-6:00 p.m.          (S) Dr. John Rosemond
                        Treating the Strong-Willed Child and Teen Proofing
3:30-6:00 p.m.          (D) Dr. Eugene Roberts and Dr. William Hohlt
                        Implant Anchored Biomechanics: Expanding the Scope of
                        Orthodontics and Dentofacial Orthopedics
6:30-8:30 p.m.          Reception in the Exhibit Hall

Friday, October 27
7:30-9:30 a.m.          Opening Breakfast
                        Awards and Mystery Celebrity
10:00 a.m.-4:00 p.m.    (D) Dr. James McNamara
                        Straightening Teeth and Faces: Practical Lessons Learned
                        During the First Forty Years
10:00 a.m.-4:00 p.m.    (S) Ms. Char Eash
                        Actions Speak Louder than Words!
                        Growing an Orthodontic Practice in a New Economy
6:00 p.m.-              Social function in Baytowne

Saturday, October 28
8:00-9:30 a.m.          (D) Dr. Vince Kokich Jr
                        Anterior Dental Esthetics: What Every Orthodontist
                        Should Know
8:00 a.m.-3:30 p.m.     (S) Ms. Char Eash
                        Numbers, Numbers, and More Numbers! How to Collect
                        and Utilize the Orthodontic Practice Numbers from each
                        Job Design
9:30-10:00 a.m.         General Assembly
10:00-10:30 a.m.        Doctors’ Break in Exhibits
10:30-11:30 a.m.        Staff Break in Exhibits
10:30 a.m.-3:30 p.m.    (D) Dr. David Sarver
                        Tooth Shape and Proportionality: How Recognition and
                        Treatment Can Result in Better Smiles
                 SAO FUTURE MEETINGS

October 31-November 4, 2007   Westin Diplomat Resort and Spa
                                          Hollywood, Florida
November 5-9, 2008                     Gaylord Palms Resort
                                                Orlando, FL
September 23-27, 2009                       The Homestead
                                            Hot Springs, VA
September 22-26, 2010                        The Broadmoor
                                       Colorado Springs, CO

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