This Bay Area Townie, already a proponent of a high-tech office, leapt into action to treat patients during the COVID-19 pandemic
Orthodontists spend most of their working hours in their practices, so they don’t get many opportunities to see what it’s like inside another doctor’s office. Orthotown’s recurring Office Visit profile offers a chance for Townies to meet their peers, hear their stories and get a sense of their practice protocols.
In this issue, we visit Dr. Jasmine Gorton, a Bay Area Townie who runs a certified Green Business in a LEED Gold Status building. An early adopter of technology who’d already kept her eyes peeled for the next best thing to enhance treatment for her clients, Gorton quickly took action after the COVID-19 pandemic hit in early March so her practice could offer virtual treatment and consultations.
Keep reading to learn how she and her staff have managed to keep her practice going, and how her travels and experiences have influenced her unique treatment approach.
Name and credentials:
Jasmine Gorton, DMD, MS, certified member of the American Board of Orthodontics
• UC Berkeley: Bachelor’s degrees in integrative biology and social sciences
• Harvard University:
Doctorate in dental medicine
• University of California San Francisco: Postdoctoral fellowship in growth and development; master’s degree in oral biology; certificate in orthodontics
Marin Ortho (Gorton & Schmohl Orthodontics), Larkspur, California
1,850 square feet
You knew that you wanted to be an orthodontist when you were 8. How did you come to that decision at such a young age?
I was “buck-toothed” (Class 2, Division?1) and broke my front tooth, which is a risk with excess anterior overjet and proclined upper incisors. That prompted my dentist to refer me to an orthodontist for early treatment.
My orthodontist belonged to a Ricketts international study club and ran a very modern practice. His progressive treatment techniques and focus on making every patient feel special really stuck with me. He made going to his office feel like a party with friends, and he was patient with my curiosity and fascination with his tools. Additionally, I’m grateful that I was offered a non-extraction treatment approach—that was unusual at the time.
(A shout-out to Dr. Alex Axelrode for being such an inspiration to not only me but also his two sons, who both became orthodontists and carried on with his practice!)
Tell us about some of the work you did after graduating.
After finishing my orthodontic residency, I worked as the associate to a busy one-doctor private practice just outside of Zurich. I’d always wanted to live abroad, and Switzerland was my top choice because of its natural beauty, multiple national languages, excellent chocolate and competitive pay. I feel so fortunate to have had that opportunity!
Upon returning home to the San Francisco Bay Area, I joined Dr. Bill Schmohl, a solo practitioner in Marin County. He was unique in many of the same ways that my childhood orthodontist had been, with unusually progressive techniques and an emphasis on the patient experience. He was also passionate about his work and excited about orthodontics. I worked as his associate for two years, before buying the practice 100% at the two-year mark. I’d been self-supporting since I was 18 years old, and despite working full time year-round, I was still carrying about $400,000 in student debt and had no savings. Therefore, the prospect of purchasing a successful (i.e. expensive) practice with no money was rather daunting! I ran the numbers by my accountant at Thomas Doll, who advised me that if I could live off my current associate’s salary and maintain the practice at the current level, it would be possible to pay off the practice loan in five years, so I jumped in.
How has the practice evolved since then?
The loan for the full price of the practice with interest was drawn up directly with Dr.?Schmohl, who had a five-year contract to stay on as my associate. That written contract expired long ago and he still continues on, because we enjoy working together and we believe that it benefits the patients. In light of Dr.?Schmohl possibly retiring someday, and to accommodate practice growth, I’ve added a second associate, Dr. Sona Bekmezian. We explain to the patients that we’ve all trained at UCSF and share the same treatment philosophies, so we can treat the patients interchangeably.
I’ve tried to follow Dr. Schmohl’s excellent example and since the purchase in 2004, we’ve moved to a more ideal macro location (2014), increased our clinic days from three to four (rotating schedule) and doubled production and collections.
We follow modern techniques as they are introduced and stay very active in orthodontic groups such as the (Tom) Pitts Progressive Group, the Ormco Insiders product development group and the Schulman Group. We also participate in office visit training programs for both orthodontic residents and dental assisting students.
What’s it like working with two other orthodontists? What’s the doctor–patient ratio, and how do you divvy up your time?
It’s extremely rare to have two or three orthodontists working interchangeably on patients, and at the same time! We have been fortunate to have the financial flexibility to allow for two doctors to work in the clinic simultaneously and we enjoy live, real-time sharing of cases.
That being said, all three doctors are proficient with various forms of virtual communication, and our experience with COVID-19 has fine-tuned that even further. We are now able to share ideas on patients in real time and/or same day via text (using Podium via front desk or personal cell), video chat (using Zoom) or email (via Google) to provide our patients with multiple-doctor input on their cases even when only one dentist is present in the clinic. We’re the only office in our area offering clinic Monday through Friday and we’re able to balance our work and personal/nonclinical responsibilities well by sharing the assigned clinic time. This is especially helpful in the case of personal/business travel, allowing us to remain open for our patients year-round even in the holiday season and summer. In a typical week, each of the three doctors will work one to two days to provide coverage for patients Monday through Friday.
Your practice is a certified Green Business in a LEED Gold Status building. Why did you decide you wanted this distinction? How do the certain standards translate into your orthodontic work?
LEED stands for Leadership in Energy and Environmental Design. We had already been implementing “green” measures in our previous practice location, as an extension of our own personal philosophy: We want our practice to reflect who we are. With the move to the new office space, we were completely gutting the space and starting a fresh buildout from the ground up. This allowed us the opportunity to incorporate into the construction process all the required features of LEED certification.
Our buildout was done under serious time constraints, because it wasn’t known when they would begin demolition of our old office space. As such, the entire total time for demo and buildout, from signing the contract to moving in, was less than three months—and within the budget determined by the bank loan! Although we did not believe that we had either the time (estimated 90 additional days) or the budget (estimated $60K) to pursue LEED certification of the office space during the buildout, having it built to LEED certification made it easy to obtain our county’s “Green Business” certification, which is based on the same parameters.
LEED-certified office spaces cost less to operate, reducing energy and water bills by as much as 40%.
Money saved can be reallocatedto attract and retain top employees, expand operations and invest in emerging technologies.
An increasing number of patients suffer from hypersensitivity reactions. Ecologically conscious products minimize the risk of an allergic reaction being triggered by the office environment. In recognition of this trend to more sensitivity, we offer orthodontic treatment with materials with little to no reactivity: Invisalign polyurethane aligners (rinsing before wear usually enough; otherwise, a hypoallergenic option is available); sapphire and titanium brackets with beta titanium wires are also available to address a possible nickel allergy (the most common allergen in orthodontics, per the NIH). We have also used latex-free, powder-free gloves exclusively for many years and stock vinyl gloves for the occasional reported nitrile allergy.
1. i-Cat Flex CBCT. Invaluable for diagnostic reasons and screening children for airway constriction, ectopic eruption and root positions.
2. iTero Element scanner. Takes the place of impressions. Less messy, easier on the patient and more detailed and accurate. We chose this scanner over others because it integrates with Invisalign.
3. Invisalign. More comfortable, gentle and hygienic approach to tooth movement. We now offer it interchangeably with fixed appliances for nearly every type of treatment, and we don’t have a fee difference for aligners versus fixed.
4. SprintRay 3D printer. We can send a scan from our iTero scanner directly to the printer and print models of patients in a little over an hour, depending on how many we’re printing at a time. We can fabricate models and deliver retainers to our patients with a same-day turnaround. It’s also possible to do same-day turnaround for aligners.
5. uLab. For less complex cases, uLab software can be used for in-house fabrication of aligners in place of Invisalign. We have tried other software companies in the past and found uLab to be closest to the functionality we were accustomed to in ClinCheck. Our treatment coordinator does the preliminary uLab setups, which are then reviewed and modified as needed by a doctor.
We can make aligners for patients in our office using an iTero scan sent electronically to our uLab software, uploaded to our SprintRay 3D printer, then vacuformed on our Biostar and trimmed by hand (until we can get a uContour trimmer!). This is all organized by EasyRx software for tracking. We kept our old Form2 3D printer as a backup.
What steps did you have to take to become a Green Business? How does the certification process work and how often do you have to renew it?
We found the green certification process to be very straightforward. We looked it up online and our team member who does our ordering filled out the questionnaire, checked for compliance and coordinated the government inspection visit. We have already had one renewal inspection (coordinated by the same team member), so it seems renewal is every five years.
The website gbci.org is a great resource for looking at green programs at a national level.
Does your Green Business status help you market to new patients? Do patients specifically come to your practice because of that?
Environmental responsibility is increasingly becoming an expectation, and our patients have commented that they appreciate us making an effort to be green. The primary deciding factor to come to our office still seems to be a recommendation from a doctor or friend, in reference to the quality of care, the results and the patient experience, and the green certification ties into the customer experience component. Though it’s not a driving factor to come in, it may reinforce their decision to stay.
Tell us about your living plant wall.
I love nature and prefer to be outdoors rather than indoors. Our previous office had openable windows and a garden our patients could see from the chairs, and we didn’t want to give that up when we moved into a professional office complex. Aside from the natural air filtration and oxygen the plants produce, living walls are associated with natural beauty and a sense of tranquility and well-being.
As an early adopter of technology, what are some items that you’ve had your eye on and hope to implement in your practice in the near future?
We have two items on our wish list. The first one is a robot, the uContour trimming machine, that can work in conjunction with uLab software for in-house clear aligners. This can decrease the staff time commitment, which we see as the biggest barrier to a more aggressive adoption of in-house aligners.
The second item is something I’ve wanted since it was first being designed at UCSF while I was in the lab as a student. Now commercially available, the Solea carbon dioxide all-tissue laser is more suited to a pedo–ortho practice than a stand-alone orthodontic office. However, I’ve always dreamed of having an office that did not look, smell or sound like a dental office. While we have achieved the first two goals, the sound of the handpiece taking composite off the teeth after attachment or bracket removal really detracts from an otherwise peaceful atmosphere! With this particular laser, composite can be removed efficiently and quietly without harming the teeth.
Your practice is in the Bay Area, one of the areas in California under serious shelter-in-place orders during the COVID-19 pandemic. How has your practice changed and adapted to this new normal, and what did this mean for treating your patients?
Our early adoption of technology has served us well during the COVID-19 office closures.
This is a list of what we were using, including some new products, that have helped us continue to serve our patients now and for when we return. Everything is available on my mobile phone. The rise of DIY orthodontics underscores the ever-increasing importance of convenience for our patient base:
1. Virtual meetings for staff, patients and doctors. I had already used Zoom to give webinars and found it intuitive and easy to use. (When used properly, you don’t need to worry about Zoom meeting “bombers”!) It was natural, then, to use it for virtual staff meetings after the closure, and I believe that staying connected face-to-face really helped with some of the more difficult decisions the practice was facing with our workforce. Because it offers an easy way to share your screen, it was a great way to review COVID-19-related treatment plan changes, especially for Invisalign patients whose cases had been redesigned to delay the placement of attachments and IPR to allow for mailing aligners.
2. The next step was to formalize our existing online virtual consultation process for new patients by using SmileSnap, because Zoom video quality is typically not a high enough resolution to be diagnostic for orthodontic concerns. By previously uploading guided tutorial photos, it improves the quality to at least a level of discussion. We also ramped up an existing online software, Appointlet, to differentiate between in-office appointments and virtual appointments. This allows new patients the option of “meeting” the doctor in a live video scheduled consultation (via Zoom) subsequent to the SmileSnap assessment if they prefer more interaction. Although we can’t have the patients do their own scans at home (yet) to start aligner treatment or place their own brackets, removing the talking portion of a new-patient consultation allows for the in-office appointment to be short and focused on records gathering with our tech. In the short term, reducing office appointment times helps with accommodating several weeks of COVID-19 canceled appointments in a timely manner. In the long term, shifting in-office doctor time to outside-the-office doctor time allows for flexibility such as sitting outdoors in the sunshine on a laptop (my favorite!) or working in the car while waiting for a child to finish an activity (best with an electric car!) or from a remote “vacation location.”
With COVID-19, we also extended a virtual consultation option for existing patients to monitor and evaluate progress with elastics, treatment-plan for a further set of aligners, etc. This helps patients stay engaged with the doctors on a personal level, much as they would have experienced with coming to our office. Existing patients are also asked to send in photos by email to our doctors before the consultation, and we have an instructional video on our website we direct them to so they can take better-quality photos. Appointlet integrates with Zoom for the consultation and also with Slack to trigger a popup on my cellphone notifying me when a patient has scheduled a consultation. Even though the appointment automatically populates my Google calendar when scheduled, which can generate a reminder at the time of the event, I find the extra notification helpful for planning purposes when operating remotely in a setting that can be noisy.
3. We updated our software, which allows texting functionality on our existing office phone number, to Podium. In addition to the usual benefits of the texts being manageable remotely and showing up on your computer screen for quickly typed responses, it integrates with our practice management software to allow group texts by scheduled day or by patient status without manually entering any numbers. It also offers a “webchat” widget we use on our homepage that allows our patients to text questions to our front desk team through Podium instead of being routed to an offshore bot. Podium also offers a more easily implementable way to increase patient reviews, which will become more relevant once Google unlocks its review system post-COVID.
To offset a decrease in staffing as a result of COVID and to allow our front desk team to focus on those patients physically present in the office, we also began a pay-per-minute call center team. This small group of four women within WrightChat is specifically trained in customer service techniques and has been trained by our team on how to schedule within our practice management software. They extend our call answering availability to one hour before and one hour after our normal office hours and are incentivized to take the time to respond to patients in a friendly, caring manner. They are completely isolated from an after-school rush or multitasking. Although we encourage our patients to text or email, we need to still accommodate those who prefer to call.
We are also evaluating NexHealth, which integrates with practice management software to allow patients to book appointments online 24/7. We believe the best time for implementation of this software would be once we have a confirmed date for office reopening. This not only helps us maintain excellent customer service and enhanced convenience despite a “lean” team but it also eliminates putting our front desk team in the position of trying to override the schedule template to accommodate patients, because this later translates to increased stress levels in clinic as we struggle to stay on time with an overbooked schedule.
4. Although we’d been offering Dental Monitoring to our Invisalign patients, we changed monitoring to mandatory and mailed retractors and instructions to all patients receiving mailed aligners. We also were able to jump onto Invisalign Virtual Care early and prefer the ease of use for the patients, and we also invited all active Invisalign patients to participate in that program. The advantages of Virtual Care are that there’s no additional charge for its use at this time beyond the cost of the retractors and there is no additional software to log in to. The current disadvantage is that all the monitoring is manually done by a team member, whereas Dental Monitoring uses AI to track the photos with only an alert to our team in the event of insufficient tracking. This tracking technology, together with virtual appointments and self-scheduling, allows us to take the “zoo factor” out of an overly packed schedule.
5. We use OrthoFi for patient financing. There was an initial financial pinch as more patients chose longer payment plans, but a higher accounts receivable and OrthoFi’s management of patients who restructured payment plans helped during the closure. (A shout-out to the Schulman Group, a source for many practice ideas!)
• RPE and Herbst appliances, depending on the type, from Specialty Appliances.
• Herbst appliances, depending on the type, from AOA.
• Hawley retainers from AOA (though we predominantly
use in-house Vacuform).
• Quadhelix from MediLab and Crozats from Ortek, although we predominantly use Invisalign First. If no airway issue, we may consider uLab.
•?Blugloo from Ormco for
•?Transbond XT for metal brackets and LR from Unitek for bonded lingual retainers
•?Monobond and Monobond Etch and Prime from •?Ivoclar Vivadent
•?Ortho Solo from Ormco
Brackets and Wires
• Damon Clear from Ormco (upper only, upon request)
• Pitts 21 from OC-Orthodontics (metal)
• Fuji Ortho LC from GC America for bands
Class II appliances
•?Carriere Motion 3D appliance, clear and metal, from Henry Schein Orthodontics (usually in conjunction with Invisalign)
•?Herbst appliance from AOA or Specialty Appliances (Invisalign mandibular advancement feature for less severe cases)
Class III appliances
•?Buccal shelf TADs
What are some of your more progressive treatment options?
I don’t think there’s anything in orthodontics that we’ve not tried as either alpha or beta adopters! Although we pick and choose techniques carefully before introducing them into our practice, we like to always know and try what is possible. I believe that our patients have come to know us as orthodontists who are open to thinking outside the box with our treatment plans and techniques to fulfill our patients’ preferences/goals while still maintaining excellence in our results.
We were the first to treat nearly all our patients without extractions many years ago, and then to use auxiliaries such as Herbst and temporary anchorage devices to create dramatic facial changes without orthognathic surgery. More recently, we’ve tried to emphasize to our patients how the appearance of the teeth within the smile—including the position of the teeth, the gums and the shape of the teeth—can make a big difference between a nice smile and a “wow” smile. (Thanks to Dr.?David Sarver for introducing us to tissue and incisal edge recontouring years ago and to the Pitts Progressive Group—especially Drs. Tom Pitts, Tomas Castellanos and Nimet Guiga—for showing us what can be done with adding interproximal reshaping, additive techniques and macroaesthetic considerations.)
What’s one of your favorite patient stories?
My favorite has to be the young boy who taught me the importance of sleep apnea in a growing child. We had been looking at airways on CBCT, were aware of apnea in children and treating it with expansion, but it was not until this case that I made it my mission to try to educate the whole dental/medical community on it.
Although the boy’s mom was one of my dearest friends, he had not yet been seen in our practice because he “looked OK.” During a sleepover at our house, my son mentioned that it was hard to sleep around him because he always snores loudly. I then reached out to his mom, who is a physician. She had already taken him to an ENT who had done an endoscopy and prescribed a daily corticosteroid spray. She agreed to let me take a CBCT, which showed a constricted airway. We placed a rapid palatal expander despite the fact that he had no crowding. The results in his behavior and athletic ability were so pronounced that she agreed to come speak to the local pediatric dentists to raise awareness. He was able to stop using the corticosteroid spray. Because he didn’t have the typical dolichofacial presentation and his dental arches were only slightly narrow, the pediatric dentist and I didn’t realize he had a problem, and his mom didn’t think to tell me because she didn’t think I could do anything about it. Thanks to my son, he went from not being able to run a lap around the track to winning the national water polo championships!
You just got back from Colombia after giving a talk on pediatric sleep apnea. What are some of the differences you’ve noticed about treatment in Latin America and treatment here?
I was blown away by the extreme awareness of aesthetics across all social classes and by the total transformations that were possible. Dr. Castellanos, who led the conference, takes a very comprehensive approach to his patients’ orthodontic treatment, making sure to include any cosmetic dentistry as well as cosmetic soft tissue procedures as part of his plan. The previous Miss Colombia winners are his former patients and he brings this “wow” smile concept to everyone in his practice.
Even within our patient population in Marin County, in which many people are into a holistic/outdoorsy/natural philosophy, there is so much we can do for them aesthetically with minimal invasiveness. I’m always surprised by how much patients appreciate those finishing touches that are so rejuvenating, even those who had said that they didn’t care how they looked. Even more important is to set our young patients up for success by treating them for their future aesthetics and not to their present. The aging process is predictable, and so the techniques for delaying it can also be predictably successful, all the while looking for an optimal functional occlusal result.
In our practice, we use as many dental techniques as possible to achieve long-term aesthetics. We begin with a superior anterior bracketing technique and increasing the vertical dimension of the bite when needed, including referring for Botox to decrease masseter strength for adults when indicated. (This can also be achieved with aligners and attachments.)
We recontour teeth to address mamelons and small amounts of wear or chipping, and do temporary composite or refer for bonding of any larger areas of deficient enamel due to trauma or congenitally narrow teeth. We also do interproximal reduction not just in the case of “black triangles” but also to lengthen the contact area. Instead of waiting years for spontaneous tissue remodeling after torque corrections, we immediately address gingival discrepancies with a soft-tissue laser. We aim to finish our patients with a smile arc that matches the curvature of the lower lip and adequate gingival display. I even have a standing order to our Invisalign technicians to never intrude upper anterior teeth unless specified by the doctor!
What do you like to do in your free time?
I’ve always loved to play outside! I end up swimming about 5 miles a week and trail running 30 or so miles a week, and sometimes I mountain bike, snowboard, rock-climb and go salsa dancing. For me, that’s fun with friends or family (or “chillax time” if out alone). It’s not like working out in a gym, with all the grimacing and misery that can be associated with that.
It’s probably good that these two favorite things go together but, aside from active play, I also really like eating great food, preferably shared with family and friends! I will eat anything as long as it is good, and my top favorites are Swiss chocolate, ice cream, pasta, salmon and tostones (mashed fried green plantains).
What’s something you’d like to see orthodontics do differently, as a profession, within the next 10–15 years? What technological advances would you like to see?
It would be nice to see us reclaim our status in the public eye as health care professionals, but I’m not sure that’s realistic.
I got into this because I wanted to do for others what had been done for me, and I’ve worked really hard at school and in my practice to be the best I could be for my patients. I think that patients “get it” once they’re in the practice, but there is more and more confusion about what orthodontics is and whether it matters whom you go to for care. The difference used to be between going to a modern orthodontist and an antiquated one; then there were “ortho-dentists,” and now DIY. Technology is awesome, but at least for the next 10–15 years, it will still be better for the patient’s health and aesthetics if the application of technology is overseen by an experienced, trained specialist in the field.
As far as technological advances, I’m already very ready for being able to print the aligner material in-house with amazing software. At the moment, the printable aligner material is too stiff for treatment and the in-house aligner software, though good, still is not equivalent to the capabilities of the Invisalign software. The laser scanners for aligners need to reduce to the size of a pen, the way the diode lasers did, and the refinement scans done by the patients using their cellphones should stitch the new data onto the initial scan anatomy for accuracy. Further optimization of simultaneous tooth movements would be a way to finish treatment much faster in a healthy and comfortable fashion.