Pick your battles wisely

clear-alignersGeneral practices across the country now offer patients clear-aligner treatment plans—and that’s a good thing. But when should a dentist refer a patient to an orthodontist? Kerryn Ramsey investigates

Clear aligners revolutionised orthodontics by removing the stigma of wearing braces. While teenagers embraced the concept, it’s the adult population that’s really responded to this new technology. Men and women can finally have their teeth straightened without sporting a mouthful of metal.

There are a number of different brands of clear aligners on the market including Clear Correct, ClearPath, Truline and SmileTRU, but the market leader by a significant margin is Invisalign. Align Technology Inc, creator of Invisalign, launched the product in the US in 1999; by March 2015, the company estimated that, worldwide, three million patients had been treated with Invisalign.

The big game-changer associated with Invisalign and other clear aligners is that, with the right training, they can be fitted in a general dental practice.

“The scope of practice that a dental practitioner can provide as outlined by the Dental Board of Australia includes orthodontic treatment,” says Dr Peter Alldritt, chair of the Australian Dental Association’s Oral Health Committee. “Clear aligners are an excellent treatment option to offer patients. Their popularity has exploded thanks to adults choosing not to have metal braces stuck on their teeth. This has created an added income stream in a lot of dental practices.”

While there has always been some blurring of the roles between general dentist and specialist orthodontist, the growing popularity of clear aligners has seen general dental practitioners doing more orthodontic work than ever before. And this is where problems can occur. While clear aligners can be an effective orthodontic treatment tool, there are limits to what they can achieve.

“There’s no real issue with dentists doing orthodontics if it’s within their scope of practice and competency,” says Dr Howard Holmes, orthodontist and spokesperson for the Australian Society of Orthodontists. “However, there is evidence of some dentists with limited orthodontic experience getting in too deep with orthodontic treatments and then struggling to achieve satisfactory outcomes.”

A lot of these problems centre around training. While an additional three-year master’s degree with clinical, didactic and research components is required to become a specialist orthodontist, undergraduate level orthodontic training is extremely limited. Some clear-aligner accreditation courses are just a couple of days in length with no hands-on clinical training.

“If a dental practitioner is going to incorporate a new technique into their practice—whether it’s orthodontic, endodontic or cosmetic—they need to have education, training and competency for whatever they are doing,” says Dr Alldritt. “Dentists need to be mindful that their attendance at a clear-aligner course does not turn them into a specialist. This sort of belief is disrespectful to registered specialists who have spent years undertaking a Master’s degree to achieve the highest level of knowledge and skills.”

While complex cases should always be referred to an orthodontist, clear aligners are a perfect solution for the correction of less severe tooth alignment problems and minor malocclusions by a GP dentist. However, difficulties can sometimes arise when making a judgement call about your own skill set. The dentist needs to consider their knowledge base, competency, proficiencies and experience before deciding whether or not to refer a patient on to an orthodontist.

“When a case becomes problematic and the practitioner feels they’re in too deep, they have to be prepared to tell the patient that the treatment is not going according to plan. They need to explain that there has been some complications and they are going to be referred to a specialist.”—Dr Peter Alldritt, chair, Oral Health Committee, ADA

“Unfortunately, for a dentist who hasn’t done a great deal of orthodontic diagnosis and treatment planning, what looks like a simple case can suddenly turn into quite a difficult one,” says Dr Holmes. “The more complex malocclusions should be referred to a specialist from the outset but even easy cases can end up needing specialist assistance when things don’t go to plan.”

Dr Paul Rollason of Absolute Dental Care in Taringa, Queensland, undertook an Invisalign course in May last year and has been offering the clear aligners in his practice since then. The course consisted of six sessions, a number of theory lessons and a practical component where one of his patients was fitted with Invisalign.

Dr Rollason found the course to be comprehensive and very effective. “The beautiful part about Invisalign is that they have a team of specialists in Sydney who can help direct you,” he says. “There’s a lot of support so you’re not left out on your own. It’s an ongoing education, as far as I’m concerned.”

It’s all about picking your cases. While Dr Rollason is happy to treat relatively straightforward teeth straightening cases with clear aligners, he’s also prepared to refer to an orthodontist if required. He was also happy to take the advice of the Invisalign specialists. “I had one case where I sent photos, scans and X-rays to the Invisalign team and they contacted me immediately,” he says. “They told me to leave this one alone and refer the patient to an orthodontist. Their expertise saved me and the patient a lot of trouble.”

If a dentist offers clear aligners—and only clear aligners—as an orthodontic solution, then there may be a limit to the results they can anticipate. Sometimes clear aligners may not be the best way to treat a condition but their convenience and aesthetic appeal can have the client opting for compromised treatment, especially if they are not offered alternatives. An orthodontist can offer a full suite of orthodontic solutions and is more likely to identify potential complications from the outset. All reasonable treatment options and costs can then be discussed and proper informed consent obtained.

orthodontics“Clear aligner technology has certainly improved over the past 15 years,” says Dr Holmes. “However, there’s still a very steep learning curve, so it’s important to start with simple cases. A decent background in orthodontic treatment planning and biomechanics is also a must. I’ve been an Invisalign accredited orthodontist since 2003 but I still find fixed braces are a better option for some patients seeking aligner treatment. Sometimes these patients choose to proceed with aligner treatment anyway but they do so with full knowledge of other more ideal treatment options. Furthermore, for clear aligners to work effectively, the patient needs to be extremely cooperative and wear their aligners at least 22 hours a day. When this is not the case, ceramic or lingual braces can be offered by an orthodontist.”

Clear aligners have been a valuable addition to the dentist’s repertoire of treatments. They are effective, comfortable, virtually unnoticeable and patients love them. They bring an added income stream into a practice and patient satisfaction is high.

However, Dr Alldritt makes the point that it’s important to be honest in your appraisal and aware of your limitations. “When a case becomes problematic and the practitioner feels they’re in too deep, they have to be prepared to tell the patient that the treatment is not going according to plan. They need to explain that there has been some complications and they are going to be referred to a specialist.”

While there has always been a crossover between general dental scope of practice and specialist orthodontic practices, the advent of clear aligners has seen it accelerate in recent years. “Invisalign and other clear aligner courses are often marketed to general dentists as a way to increase their business and build the bottom line,” says Dr Holmes.

“This is not necessarily a bad thing. However, attempting to treat complicated conditions beyond a dentist’s skill set could actually end up impacting negatively on their practice and reputation. When general dentists treat their patients with clear aligners, they just need to be aware of the product’s limitations and the scope of their own ability. Pick your cases carefully and refer to an orthodontist when necessary.”

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