As all GPs know, some of the most problematic retention concerns involve patients whose orthodontic treatment was provided by someone outside your referral network. This could be a patient who has moved into your area or one treated by an orthodontist who practices close by, but to whom you do not typically refer.
The latter can represent an extremely sticky wicket. It can be particularly difficult to transition retention responsibility from someone to whom you could refer, but do not. Since more patients self-refer for orthodontic treatment than for any other specialty discipline, this a common scenario.
For these patients, consider the following:
- How long ago was active treatment completed?
- Does this patient still have a treatment relationship with the orthodontist or the dentist who provided the orthodontic treatment?
- Has there been any relapse?
- Does the patient have a “Plan B” for retention?
- What other dentistry does this patient need?
- If a new retainer or retention strategy is appropriate, how do you decide what type of retention to employ?
As may be obvious, the answers to some of these questions are purely clinical, some have a behavioral aspect, and some are both. In addition, some address risk mitigation. Regardless of what you do, you would like to satisfy the patient's needs and wishes, protect his/her rights, and protect yourself. I will elaborate on each of the questions posed above.
Considerations for orthodontic patients outside your referral network
How long ago was active treatment completed?
If active treatment was completed fairly recently, the treating orthodontist may still be expecting to see the patient for retention checks. Most orthodontists want to monitor retention for some time after active treatment has been completed. I know I do.
The reason I include a period of retention after active treatment in my treatment fee is because I would like to know if the patient is having any problems with the retainers, and I continue to modify (usually reducing) the amount of retainer wear over time (for removable retainers, obviously). I especially want to know if any changes in tooth position are occurring, many of which can be mitigated if recognized early enough.
If the patient is still in this phase of retention - that is, it is still being determined how well the current form of retention is maintaining the treatment result - it is in the patient's interest (and yours) to encourage the patient to let the orthodontist continue managing retention. My ortho fee typically includes up to two years of monitoring retention.
I also consult with the referring dentist (or the general dentist of record if the patient was self-referred) prior to treatment regarding transfer of retention after this two-year period. At the last retainer check visit for my patient, I review what agreement I have made with his/her general dentist. If the patient comes from a GP with whom I have no agreement, or one who does not want to have a role in managing retention, I give suggestions for when they should come back to see me. I am happy to see patients for retainer checks after the period of time included in their treatment fee, but these are then separate visits at an additional fee.
Does this patient still have a treatment relationship with the orthodontist or the dentist who provided the orthodontic treatment?
If treatment was completed more than 18 to 24 months ago, chances are treatment has been deemed complete. Ask the patient if he/she believes that is so, and what final instructions were given regarding retention. Especially if the doctor who provided the orthodontic treatment is in your community, I think it is prudent to verify that treatment is complete before you advise a patient about retention.
In addition, if you make a practice of asking the treating orthodontist what instructions were given to the patient regarding retention, you signal to them that it is something to which you are routinely paying attention. If the patient was treated by an orthodontist to whom you could refer but do not, you will have to determine whether you think it's appropriate to discuss the patient's retention with them.
Most often this would be considered purely a courtesy, but communities differ. I know I would be happy to share with the patient's GP what instructions I had given to them at the end of treatment and pleased to know if my former patient's retention was still working for them.
All of this assumes that both the patient and the orthodontist were happy with the treatment result and both considered treatment complete. It is not within the scope of this segment to discuss how to approach the concerns of a patient who is unhappy with the orthodontic treatment result, and you should proceed with caution in such cases. That is not to say that you cannot advise the patient with regard to retention, but you should thoroughly document the patient's condition on presentation before you do.
Has there been any relapse?
If removable retainers fit well, it is reasonable to conclude that little or no tooth movement has occurred since the retainers were delivered. When I was a GP, my usual procedure in such cases was to offer to check the patient's retainers at routine re-care appointments. The benefit to the patient in doing so includes at least the following:
- It's arguably more manageable for a patient to commit to wearing a removable retainer for the next six months (just until the next check-up!) than “forever.”
- It offers an opportunity to clean removable retainers. Patients generally appreciate this.
- It allows me to inspect the retainer to see if it is in reasonable condition. I would much rather replace a nearly-worn-out retainer on an elective basis than be faced with replacing a just-broken retainer as an emergency. (This always seems to happen at the beginning of freshman year of college, after the patient has moved far enough away to make coming back home really inconvenient, and isn't scheduled to come back home until Thanksgiving break. I love when that happens.)
In the case of fixed retainers, there can be movement of the entire bonded segment. Since lower fixed retainers are usually bonded canine-canine, this usually manifests itself as space distal to the canines. Absence of such spaces is a good indicator that the fixed retainers are functioning as intended.
If you observe spaces distal to the fixed segment, tongue function is the most likely causative factor, and supplemental retention may be indicated. (The presence of a tongue thrust may be indicative of other issues, which are beyond the scope of this discussion.)
You can also inspect fixed retainers to determine if the bonding appears secure, allowing you the opportunity, again, to avoid an emergency repair or replacement by recommending repair or replacement proactively.
If the retainers do not fit well, it is generally a good indicator that some post-treatment tooth movement, or relapse, has occurred. In my opinion, the sooner relapse is addressed, the better.
As stated earlier, as GPs we often make assumptions when we see orthodontic relapse; we assume that the patient did not wear his or her retainers, and that's that. In my opinion, especially when someone has made the investment of time, effort and money in orthodontic treatment, we owe it to them to investigate what has contributed to the relapse.
There are many factors that contribute to patients' failure to wear retainers other than non-compliance or neglect. (Some of these factors are explored later.) Simply asking whether the patient is okay with the current tooth arrangement is a straightforward way to open the discussion. If the patient is satisfied with the current tooth position, then you have sufficiently explored the matter unless the current tooth position presents a compromise to other treatment goals.
If the patient is still wearing retainers, you need to make an assessment as to whether the retainers are actually retentive. Even poorly-fitting retainers can be better than nothing, but often they do nothing to maintain the relapsed tooth position, and continued relapse can occur even if they are worn.
As GPs, we have all had patients who tell us, for example, “I don't want to have ortho again, and I'm okay with this amount of misalignment, but I don't want it to get any worse.” When you have a patient like this, you may want to consider a new retainer that will better maintain the relapsed tooth position. A discussion of retainer options in circumstances like this is discussed later.
Does the patient have a “Plan B” for retention?
For this question, let's assume the patient is wearing retainers, they fit well and you observe no relapse. The next thing you'd want to know is, what is the plan if they lose or break a retainer; do they have a “Plan B”? Next to simple non-compliance, a lost or broken retainer is probably the most common reason that patients suffer relapse. Because there is typically no specific plan in place for dealing with retainer loss or breakage, patients often do nothing. Their orthodontist may have not given them instructions to make arrangements to have a lost or broken retainer replaced, nor sufficiently emphasized the importance of doing so. They may believe (and we all know this belief is common) that relapse won't occur X number of months or years after treatment is complete. They may think, “I'll call my orthodontist/dentist if I see anything change.” By the time they decide to do something, they may have suffered more relapse than is easily remedied.
Consider an alternative strategy: give the patient a Plan B as part of your retention strategy. I do this by giving my patient a back-up set of retainers and instructions to call me to arrange for replacement of the primary retainers in the case of loss or breakage. When I have an agreement with my referring GP about this, the patient can call him/her to arrange for replacement instead of me. My fee includes two sets of retainers, which does not materially increase the cost of treatment.
As an example of this, a common retainer strategy for me is a removable Hawley retainer for the upper and a fixed lower lingual retainer. In addition, I give patients a set of Essix-type retainers that are meant for “emergency backup” only. (In this example, the lower Essix-type retainer is made on a model of the lower after the fixed retainer has been bonded.)
I instruct the patient to put the Plan B (“emergency backup”) retainers in a safe place, where they know they can find them (the safe place I always suggest is in a retainer case on the top shelf of the freezer). If they lose or break the Hawley, or the fixed retainer comes out, getting a replacement is much less of a crisis.
Also, if necessary, the Plan B retainer can suffice for a short period of time, such as until the next time they get home from college, or if they need some time to save up to pay for replacement retainers. (I make it clear in my initial fee discussion, and at the retainer delivery appointment, that replacement of lost or broken retainers is at an additional fee.)
This strategy, both explicitly and implicitly, conveys to my patients that retention is important. It is by design that the Plan B retainers are called the “emergency backup system.” I want my patients to consider loss or breakage of a retainer an emergency; something that will compromise the result we've all worked so hard to achieve.
However, I don't want to put them or me in a situation that is actually urgent. I have, in real life, more than once had a parent get the emergency backup retainers out of the freezer and FedEx them to the college student, who then has adequate retention until arrangements can be made for new retainers to be fabricated. So much disappointment is thus avoided with just a little planning.
What other dentistry does this patient need?
This is a variation of the previous Plan B scenario. Any dentistry needed by the patient potentially compromises retainer wear.
For example, let's say you do a crown prep on an upper first molar and place a provisional crown. The patient goes home and notices that she cannot put her upper retainer in. She thinks, “It'll only be a couple weeks until I go back for my crown. I'll ask my dentist about my retainer then.” Or, “It's been eight years since my braces came off. My teeth won't move after all this time.” Or, worse, “If it was important that I wear my retainer with this temporary crown, my dentist would have said so.”
By the time she comes back to have her crown placed, she has had some minor relapse of #8 and #9. She blames you. This does not make for a good day. It is not the point of this discussion to solve this problem after it has occurred, but to recognize that, with proper planning, it could have been avoided.
How much better might it have been, having known that the patient was still wearing retainers, to counsel her ahead of time that an alternative method of retention might be required while the temporary crown was in place, and that a new retainer may be needed after the crown was cemented? Not only could you have avoided the problem (and, arguably, responsibility for the problem), you create the impression that you know what you're doing and you are mindful of the patient's commitment to her retainer wear. Not only that, you have a patient who will pay you, with gratitude, for making her a new retainer.
There are endless variations on the previous scenario: third molar extraction, perio surgery and almost any restorative treatment. Simply being aware of whether the patient is wearing retainers can save you and your patient from unnecessary risk of relapse. A little creativity goes a long way in these cases.
If a new retainer or retention strategy is appropriate, how do you decide what type of retention to employ?
If you have a patient who has lost or broken a retainer, the first inclination is to replace it with the same type of retainer they had. It helps to remember, however, that there are many devices or appliances commonly employed by GPs that, in addition to their primary function, serve beautifully as retainers as well.
For example, in my office we make bleaching trays and Essix-type retainers exactly the same way, out of exactly the same material. A full-coverage bite appliance makes a great retainer, as well as addressing occlusal or joint issues. I have the luxury (I think it's a luxury) of having both my practices in offices where GPs also practice, so I have the opportunity for on-the-spot consultation regarding what type of appliance will best serve the needs of our patient.
If you do decide to replace a lost or broken retainer with the same type of retainer that the patient had, it is useful to know the basics of prescribing, fabricating and adjusting retainers. Those will be covered in a future segment.
To conclude, being aware of whether or not your patients are wearing retainers allows you to help them in their efforts to maintain their orthodontic treatment result, and to help you avoid unknowingly creating obstacles for them. In addition, it offers you an opportunity to enhance your relationship with orthodontists with whom you work.
Cheryl DeWood D.D.S., Ph.D. is a contributing author to Spear Digest.