Orthodontic relapse and the need for an interdisciplinary solution

by Rob Veis, DDS

For more on this topic, go to www.dentaleconomics.com and search using the following key words: orthodontic appliances, orthodontic relapse, Appliance Therapy Group, CDT codes, recall appointments, modality, Dr. Rob Veis.

Shift happens. Orthodontic relapse happens — and it may have very little to do with treatment source, or the mechanics, or the planning. The important operative questions in regard to the problems of crowding and orthodontic relapse are:

1. What is the solution?
2. Whose responsibility is it to provide that solution?
3. How is it to be implemented into a program of interdisciplinary care and maintenance?

As a practicing general dentist, I see many adults whose chief complaint is crowding of the lower teeth — sometimes upper as well. Many received orthodontic care when they were younger and have not worn their retainers since then. Others never had any orthodontic treatment, yet complain that their lower teeth are suddenly becoming crowded.

Prevention of dental crowding is possible. Permanent retention is the only reliable solution — if an interdisciplinary approach is developed.

Who to do it

Most orthodontic patients move away and/or lose touch with their orthodontists. The orthodontist is out of the picture until a problem returns and the patient is referred back for retreatment — and even then, sometimes not.

The general dentist often lives under the misconception that care is ongoing from the orthodontist. On the opposite side, the orthodontist no doubt lives under a similar misconception. The result is a “no man's land” where neither orthodontist nor dentist goes — a limbo where the finger gets pointed, but not enough gets done as a result.

There is no adequate modality for follow-up in treating the finished orthodontic patient. From the orthodontist's standpoint, it's not about maintenance of former patients' conditions.

Once the work is done, it's done. End of story and, since we know (and it's proven) that retention is forever, that means all these patients are getting lost in the shuffle to varying and maddening degrees.

This “loss” is your potential gain — because what has to happen is that there has to be a better method for taking care of all of these postorthodontic patients and those nonorthodontic patients whose teeth are destined to shift anyway. It's very clear that the general dentist is the solution and the rightful resource for making sure that there is some methodology in place to prevent patients' teeth from shifting.

The responsibility for evaluating patients' post- orthodontic occlusions rests in the hands of the dentists and hygienists who will care for them for the rest of their adult lives. These professionals are essentially the sole line of defense when it comes to providing retention services that will be needed indefinitely.

How to do it

You need to develop a regular postorthodontic/permanent retention program in your office — no different from how you would develop a regular periodontal hygiene recall system. Because it has never been done before, I get blank stares when this subject comes up in the course of my travels. Where to begin? How do I charge for it? What to do?

There is much general dentist confusion regarding the actual economics of integrating this vital program into their service offerings.

Immediate priorities include the development of a proper screening process, a retention and relapse examination, treatment (when necessary), a regular recall process, informed consent (that indefinite retention is essential).

Step 1: Create a screening form
Questions to be addressed should include:

• Have you had orthodontic treatment?
• Do you wear a retainer(s)?
• Do you visit your orthodontist for retainer adjustment?
• Have you been made aware of the necessity of indefinite retention?

Step 2: Perform an intraoral exam
Step 3: Chart the changes
After the exam and periodontal probings, impressions are in order — all in the interest of evaluating the changes in occlusion that have resulted over time.

Step 4: Treat the condition
Once the changes or potential changes are indicated, we need to get in there and prevent them from occurring or worsening — with a final retainer, active retainer, or bruxism splint.

Step 5: Decide on a fee
Consider retainer exam fee, adjustment fee, replacement fee, and limited retreatment fees.

When adding any new procedure to your practice, it is clear that you need to make enough money at it to make it worth your time. If you can't make the procedure profitable, you simply won't continue. Ask yourself what it costs you to run your office per hour and what do you want to earn per hour. Once you can answer these questions, you will be able to set your fees.

Step 6: The insurance game
You can find the insurance codes — the same ones that orthodontists use — for setting fees and receiving payment by going directly to the CDT Code Book. Either the periodic oral evaluation (D0120) or limited oral evaluation–problem focus (D0140) may prove appropriate for exam fee billing. Other appropriate codes would include orthodontic retention appliances (D8680), repair of orthodontic appliances (D8691), replacement of lost or broken retainers (D8692), and/or rebonding or recementing of fixed retainers (D8693).

When to do it

After charging for the initial exam and delivery appointment of the final retainer, you will need to recall the patient every six months and (as necessary) invoice using the orthodontic codes for a recall exam. Should a need arise for making an active orthodontic retainer (because of relapse), that can be done as well. If limited tooth movement is required, but retention is not — and the patient doesn't need to be sent back to the orthodontist to accomplish this task — there are codes for limited orthodontic treatment in the CDT reference (D8030, D8040).

Dollars and sense
The economic message here is simple: You can properly code the patient, get the insurance billing, and get paid for your time.

For example, lab fees for the average upper and lower Hawley retainers are approximately $65 each. You may want to charge the patient $390. The picture includes the appliances and a minimum of two appointments. One appointment is part of your regular exam process and the second appointment is to deliver the appliances.

Recall appointments then need to occur every six months — you make the appropriate adjustments, evaluate performance, clean, correct, and maintain. These appointments occur at the patient's recall visit but get billed out for the appropriate procedures.

Your “costs” conversation with the patient should cover the “an ounce of prevention is worth a pound of cure” concept. A bent wire in a retainer can work to worsen the condition originally treated or generate abnormal tooth movement rather than correct it. A splint can become so dirty and grungy that it's actually causing or enhancing the spread of bacteria in a patient's mouth.

I tell my patients the cost of recall appointments and adjustments — a yearly investment of roughly $100 — beats the cost for reconstruction in a few years after they have ground their teeth down. That's what's going to happen if there is an adjustment needed, but not made early on.

Recall appointments ensure that the patient wears the retainer or bruxism splint — preventing joint problems and teeth grinding and potential costs down the line of anywhere from $2,000 to $25,000.

There are three operative messages here:

1. Relapse happens and the need for prevention is vital.
2. Prevention is your job because you are there. The orthodontists are too busy or are simply out of the patients' “touch” area.
3. You can learn to integrate retention solutions economically into your practice, and you can learn what questions to ask during the exam, and you can get paid for it all.

Dr. Rob Veis is chief executive officer of The Appliance Therapy Group® (ATG), comprised of Space Maintainers, Inc.®, Success Essentials®, Second Opinion® The Smile Foundation®, and The Appliance Therapy Practioners Association®. For more information, visit www.TheATPA.com or call (800) 423-3270.