Embrace Progress: What’s In Your Records? by Daniel Grob, DDS, MS, Editorial Director

Pretty pictures
The American Journal of Orthodontics, with guidance from the AAO and ABO, has outlined what it believes to be a complete or clinically acceptable collection of diagnostic records if one is to publish or research case diagnosis, treatment and results.

It states:

Diagnostic orthodontic records for publication in the Journal must include, but are not limited to, the following: (1) extraoral and intraoral photographs; (2) a panoramic radiograph and periapical radiographs where indicated; (3) diagnostic casts, either plaster, digital or stereolithic; (4) diagnostic setup casts, created from either secondary initial casts or digital setups; (5) lateral cephalograms and cone-beam computed technology images when diagnostically indicated; and (6) initial and final cephalometric tracings with superimpositions.

Of course, general dentists are required to gather a certain grouping of records as well, but let’s agree that they’re rarely organized, presented and analyzed as they are in an “orthodontic consultation.”

How many exams have you performed in which you were ready to take the patient into the records room and the patient asked you to call the dentist and get the X-rays that were just taken? After an annoying delay, verifying email addresses and fax numbers, you printed or uploaded the cone-cut set of bite-wing X-rays showing the crowns of a few teeth.

Or better yet, how many patients appear with 2-year-old panoramic X-rays printed on the back of some restaurant place mat or napkin and ask you to use that for your evaluation?

From record-taking to method-making
In my “Treatment by Twelves” presentations, I refer to how Dr. Robert Keim traced and predicted the paradigm shift from static record-taking to functional or dynamic method-making.

Keim stressed the importance of attempting to predict the changing face over time, and using these predictions to diagnose and treat patients. A couple of years later, in an apparent contradiction, another article in the same clinical orthodontic journal mentioned that records weren’t being collected as often as before. Casts were being eliminated, and even cephalometric X-rays were absent from the standard repertoire. Clinicians were “winging it” with a couple of photos and hopefully a panoramic X-ray.

I’ve actually heard from a young doctor practicing in one of the “pop-up” clinics who has to use a cell phone just to gather some type of photographic record before placing braces on a patient that same day.

Recently, an editorial response in another professional journal took some jabs at the modern practice of orthodontics in some corporate settings. “Placing starts above proper diagnosis and treatment” was the implied conclusion by the writers, who documented the hypothetical journey of a neighbor who was nudged into orthodontic appliances in one visit with diagnosis, contract and appliances—apparently placed all within a single appointment.

We’re busy in October!
I remember joking with my staff 20-some years ago about being “busy in October” after making it through the summer rush.

For those new to the profession, standard operating procedure back then was to perform a certain number of exams during the morning hours for the initial exam. Patients were reappointed for diagnostic records, then reappointed again for the after-work and school consultation, where both parents could review the findings and go over all the diagnostic records with the child present. Once all objections had been defused and the father was worn into submission, an appointment for spacers was made. One week later, the braces were placed. Whew!

If you’re following along, this moved an initial exam appointment performed in July into a start in October. It’s no wonder things have changed—they had to! (Thank you, practice consultants.)

The evolution of records
Digitization has played a part in the elimination—as well as the acceptance—of new-record gathering and keeping. While plaster-soaped casts are falling out of favor in most offices, digital scanning is becoming more popular.

Many speakers on the circuit emphasize the importance of modern diagnostic record procedures and stress that the orthodontic specialty practice is moving beyond achieving Class I molars.

If you’re paying attention to what’s happening around you, the conclusion is that we need to be more complete in our record-gathering system, not less, and do more with what we gather.

In my experience, patients who choose a practice that gathers seemingly abnormal sets of diagnostic information and then presents patients with objective findings and some subjective recommendations, tend to accept more treatment and refer more patients. (And, yes, sometimes it’s difficult to “code” for these services.)

If the goal of most orthodontic practices is to start patients, the goal becomes more attainable. Most restorative dental courses and study clubs that are taught by leading practitioners and educators (originating from the northwestern and southeastern parts of the country) stress that you can’t treat what you don’t see. For instance, CBCT is combining the cephalometric, panoramic and even periapical X-ray evaluation into one record. Intraoral scanning is allowing for almost instantaneous treatment-outcome predictions.

As I write this column, I’m reminded of a forward-thinking, experienced orthodontic practitioner in my area who’s driven by his patients’ desires. Recently he’s added the services of a general dentist to not only aid with some of the duties of orthodontic practice but also to work with gingival smile detailing at the completion of orthodontic treatment, as well as to perform some minor surgical procedures such as micro-osteoperforation to accelerate treatment.

Utilizing complete diagnostic record-gathering is the key to adding these services in his practice. Such things as smile design, airway improvement, habit correction, cancer detection and restorative dental planning are all within the scope of the modern orthodontic practice.

So … what’s in your wallet (records)?