In my article "I Won't Do Ortho," I lamented that adult patients seem resistant to the world of orthodontics, thinking that it is the same as the days when they were teenagers.

Just like cars are vastly different in make, model, color and size, braces can be many different things today. The good news is there are many ways orthodontic treatment can be more acceptable for adult patients. Still, it remains a significant roadblock for many adults to consider orthodontics as part of a restorative treatment plan.

I treat adult patients for my referring dentists all the time, so I looked to see what made the difference in case acceptance. It turns out there are some strong factors that can increase the success rate for adults to choose orthodontic treatment to improve their restorative outcomes. The secret is in the hands of you, the restorative dentist.

The 7 steps to orthodontic case acceptance

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The restorative dentist is in the best position to set the stage for patient acceptance of orthodontic treatment. If, after you complete your facially generated treatment planning (FGTP) work up, you really believe that orthodontic treatment is the best option for your patient, or at least an option they need to understand, you can influence the acceptance rate you experience. The following suggestions will help your patient keep an open mind.

  1. Sharing the idea: When you have photos as part of your new patient exam or re-care visits, your team can begin the process of introducing the idea that a change is possible. Who better than your hygienist to plant the thought that there can be benefits to the health of their teeth? Simply ask, "Can we share some thoughts with you about how you can improve your bite/discolored fillings/worn teeth/gum health?" When your patient shares their interest in discovering a possible change, you have the tools to progress to the next step.
  2. Begin with the beginning: Always begin with the Esthetics-Function-Structure-Biology (EFSB) diagnosis process and the FGTP for the esthetic treatment planning of your case. It is the essential foundation for treatment planning, for discussions with supporting providers, and will ensure you have made a complete overview of the patient's oral health. From there you will find direction for the options to present to your patient.
  3. Discuss before you refer: This is a key step for a successful conversation with the patient. When you discuss the case with your orthodontist and other specialists before you meet with the patient for the case presentation, you and the specialists all come to agreement on the benefits of orthodontic treatment for this case. It prepares both you and the orthodontist to be confident of the benefits of the orthodontic part of the treatment plan. Make a list of specific benefits you can achieve with orthodontic treatment as well as how you can complete the case without orthodontics. Determine if the orthodontic options might include full braces or perhaps a limited treatment to prepare for the restorative phase. Include a listing of teeth to be treated and note if orthodontic treatment will reduce the number of teeth to be treated or not. This discussion with the orthodontist will often lead to a diagnostic set-up/wax-up to visualize the end point. Along with your photos, here is another valuable tool for transferring the vision of the future finish from you to the patient.
  4. Using visualization: Your initial objective is help the patient see what is possible when it comes to making a change to their teeth and smile. Most people can only appreciate differences through a visual representation. It is difficult to know if we want something when we have not seen it. We have a number of ways to provide patients with a vision of what is possible. You already have their photos and templates of their specific case that can be used. In addition, patient education videos and other case finishes can give the patient a real life example. Initially, keep the focus uppermost on the patient's goals of treatment. Using a checklist system can often make the goals and additional benefits clearer for the patient, and it is a way to create something for the patient to take home with them. Once the patient is clear about what they want, the time to explain how to achieve those goals has arrived.
  5. Let your specialist support you: When the ideal result includes orthodontics or other specialty care, your introduction to the patient can begin by letting them know you have already connected with the specialists and that they are very familiar with the case. Include the notes from your previous consultation with the specialists along with the list of benefits. As the restorative dentist, you can help your patients realize that one of the best things they can do for themselves is seeking out information from your specialists. This will allow them to be fully informed and able to make this decision with confidence. Setting up the expectations for their visit with the specialists and setting the stage to have your diagnosis and treatment plan confirmed helps patients better understand their options. They are less likely to dismiss orthodontics or other specialty care without getting information first. Your planning has removed some of the unknowns and possible fears.
  6. Know the alternatives: After your presentation to the patient, the orthodontist is next in line with the case acceptance process. Because of the previous discussions with you, your orthodontist is well set up to carry your plan forward. At this point, an acknowledgement by the orthodontist of the excellent work and planning completed by the restorative dentist is in order. Presenting as a well-connected provider team is a strong boost to patient confidence. Equally important is to acknowledge the patient for their time and effort to become fully informed to make a decision that fits them. I like to confirm with patients – using their own words – what their goals of treatment are and what they want for the long- term results. Usually by now they have more information and an understanding of their problems as well as what they want as an end result. I follow up with photos of a before-and-after of a similar case to their condition, most often trying to show a case completed by their restorative dentist. I carefully point out the differences between the results using orthodontic treatment, and I am also clear about the alternatives to orthodontic treatment. That is another value in discussing the case before the referral is made. As Dr. Frank Spear has taught us in seminars and workshops, the patient who says no to orthodontics says yes to the alternatives. If I don't know the alternatives, I can't help the patient make comparisons among the other options. I also can help with discussions of phasing restorative treatment so they can ultimately complete the treatment they want.
  7. Catch the patient up with today's orthodontics: One of our final points is to familiarize the patient with current orthodontic techniques. They are often surprised about clear brackets and Invisalign as options for their treatment. And they are often surprised at the age of my oldest patient: 93. I share with the patients that most adults do not come knocking at my door excited to have braces. Once they go through this process and they understand how orthodontic treatment can restore bone and rehabilitate years of breakdown, they begin to open their thinking to new options. In the conclusion of the visit to my office, I reassure the patient that there are a lot of treatment options open to them, and that there is not a right or a wrong choice. They must make the decision based on what they believe is best for them in the long term.

Spear Resources

From No to Yes: Increasing Case Acceptance

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Example of an adult orthodontic case

This is a sample of a case that is in progress and it demonstrates how helpful it is to receive the photos and basic plan outline before the patient comes for an orthodontic exam.

It is not a perfect, polished PowerPoint presentation for a dental meeting. It contains the key photos we need to start a conversation and a basic restorative plan that may change as the patient better understands their issues and can better articulate their goals.

Communication is also one of the best investments you can make, and I highlight that below with an email exchange between this patient's restorative dentist and myself. This is the email in which the restorative dentist sent the original images.

I encourage you to put some of these steps to work in your own practice for an improved case acceptance.

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Initial email from the restorative dentist to me

Hi Donna,

A patient of mine is scheduled to see you for a consult next week. This is a combined ortho-restorative case with severe wear from both tooth-to-tooth contact and also an acid component.

The PowerPoint will show the issues: the left side has a stepped occlusal plane and the anterior wear has caused compensatory eruption. At minimum, I would see us restoring #5-11 and #21-26 due to wear alone, and possibly more if we feel that we should open his vertical. It seems to me that the occlusal plane issue could be our biggest challenge. Please gives feedback.

My response email

Thanks ____, The PowerPoint is so great for me for the consult. Thank you! I will email after I see him.

My response after seeing the patient:

Hi ____, I had the pleasure of meeting your patient and I discussed using fixed appliances. With the intrusion and space opening needed, this will not be easily/efficiently managed with aligners, at least in my hands. We spent some time discussing benefits to him in doing this, and I thought one of the greatest risks was in loss of #25. Even to replace it with an implant would require space development.

He is not driven by esthetics, and I discussed the role of good nutrition in the next 30 years as essential to longevity and quality of life. The non-treatment option I told him would have to include a night guard and, possibly, an Essix during the day to minimize any additional tooth/enamel loss. I'll let you take it from there.

During the exam I noted the 5 mm overjet in CR due to the missing #20. With the space you need for restoring the thin/worn #23-26, I think I will have created manageable overjet if I build up the incisors to 5-5.5 mm wide. I plan to do a set up to show you so I know exactly what you need for tooth size and for anterior contacts.

This may be a case where a mid-treatment build up will help me with final positioning. I warned your patient that my part of the treatment will make him look worse, but he dismissed that as a concern. He could change his mind.

I also noted low lip mobility, about 5 mm at the maximum smile effort.

If he decides to move ahead, I will make up the diagnostic set-up and set a time to review with you.

Thanks. This would be such an amazing change for him if he can give us the time to get him there.

(Click this link for more interdisciplinary dentistry articles by Dr. Donna Stenberg.)

Donna J. Stenberg D.D.S., M.S., P.A., Spear Visiting Faculty and Contributing Author.