Abstract
Orthodontic treatments can seem overwhelming, burdensome, and uncomfortable for patients, parents, and – when it comes to emergency visits – for orthodontists as well. As we evolve the industry, we must keep the patient’s experience top of mind and put them in the driver’s seat. In her article, Dr. Sima Yakoby Epstein, Founder and CEO of OrthoNu will discuss orthodontic emergencies, the impact of braces and aligners on oral microbiome, and how to empower patients to play a larger role in their treatment journey to reduce the cost of emergency visits that will help Orthodontists improve office efficiencies.
People undergo orthodontic procedures for a variety of reasons, and the overwhelming majority are satisfied with the result. However, the treatment process can be burdensome and overwhelming for patients and parents, not to mention physically uncomfortable at times. With a treatment that can last from months to years, it is paramount to keep the patient experience top of mind and ensure patients feel in control of their treatment. Orthodontic emergencies are one detractor from the patient experience – yet they impact orthodontists and their practices as well.
Pain is a substantial barrier to successful orthodontic treatment, causing patients to either not start or choose to discontinue treatment. Up to 70% of orthodontic patients report pain, most often due to orthodontic tooth movement, and 10–20% interrupt therapy early because of pain.1 High quality studies evaluating the impact of pain and discomfort related to appliance breakages on adherence to treatment are not available, but experience shows this to be a common problem.
The 411 on Orthodontic 911s
Orthodontic emergencies are unexpected issues or problems that require urgent attention. Emergencies include broken brackets or wires or loose bands, or discomfort caused by the appliance. Wire issues can, for example, cause scraping on the inside of the mouth, producing painful sores or ulcers. Broken brackets or bond failure are less often associated with discomfort but can still bring a patient back into the office. Braces and removable aligners can have sharp edges that need adjustment for comfort. The 411 on orthodontic emergencies is that many of the problems that bring patients back into the office for an unscheduled visit are things that may not actually need that extra office visit.
According to data from Gaidge Analytics, 8% of all orthodontist visits in 2022 were emergency repair visits, and these emergency visits can cost the practice up to $300 each*. Orthodontic emergencies such as wire breaks and bracket failures can be handled by the patient at home and at the next scheduled visit, but the standard at-home “treatments” involve unhygienic procedures2: using a pencil eraser to nudge a bracket back into place or a nail clipper to trim a wire could introduce unwelcome bacteria.
*Costs may vary from $100-$300.
Microbiome Matters
There are over 700 species of bacteria in the oral cavity, the second most diverse bodily environment after the gut.3 Since the oral cavity is an entrance point to the body, the attachment of the microorganisms to the hard surfaces of teeth and the soft tissues of the oral mucosa makes it easy for microorganisms to spread from one area to other neighboring sites.3 Bacterial species in the oral cavity are associated with oral infections including dental caries, periodontitis, endodontic infections, and tonsillitis. Oral bacteria have also been linked to systemic diseases, including cardiovascular disease, diabetes, pre-term birth, cancers, and pneumonia among others.3
Orthodontic devices alter the microbiome, either directly by providing a surface for colonization or through immune pathways engaged by the devices.4–6 Orthodontic devices may favor growth of bacteria associated with dental caries4 and increase the populations of potentially pathogenic bacterial species, including Lactobacillus and S. mutans.5,6 Maintaining good oral hygiene practices, such as regular brushing, flossing, and rinsing, is crucial for minimizing any potential negative effects on the oral microbiome during orthodontic treatment.
Potential challenges and considerations of oral hygiene may influence a patient’s decision to proceed with removable aligners or braces. Discussing hygienic practices with an orthodontic appliance along with the pros and cons of each treatment method are important for keeping the patient in the driver’s seat of their treatment.
Patients as the Drivers of Treatment
It is crucial to make sure that patients feel in control of their treatment. For a months-to-years long treatment regimen, patients can often feel like the treatment is done to them, rather than being an active participant in their therapeutic journey. For many, orthodontic treatment is voluntary – in a survey of Canadian orthodontic patients, 62.8% wanted a more attractive smile and 40.9% wanted to improve confidence and self-esteem, while 22.9% wanted to improve mastication ability and 24.4% wanted to improve ease of performing oral hygiene.7 For their treatment, about half of patients in Canada choose to see an orthodontist, with another two in five going to their primary dentist or following their dentist’s recommendation for treatment.7
Despite frequent device issues and general oral discomfort associated with orthodontic correction, most patients are satisfied with their treatment.8,9 That said, we have the opportunity to further improve the patient experience by reducing the inconvenience of emergency visits and reducing the time spent with discomfort related to their orthodontic appliances.
Improving Operational Efficiency
As we’ve seen, most orthodontic visits are due to a device problem causing discomfort that is in the interest of the patient to resolve as quickly as possible, yet many of these could be resolved by the patient on their own well enough to wait for the next scheduled visit. At an average cost to the practice of $300 per visit, empowering patients to resolve bracket and wire problems on their own, eliminating the need to come into the office, can have financial and operational benefits to the practice.
Visits for broken wires or brackets make up about a third of repair visits (34%, Gaidge Analytics). For an average sized orthodontic office (120 starts per year), the savings from eliminating repair visits for broken brackets or wires could save over $40,000 per year and over 3 hours of clinic time per months. For larger practices, the benefits are even greater – over $185,000 in cost savings per year and 13 hours of clinic time per month for a practice with 500 starts per year.
Tweakz® for Braces and Tweakz® for Aligners are an entirely new category of products specifically designed to address these challenges. For instance, Tweakz® for Braces features a flush distal end cutter that eliminates sharp wires by cutting and holding the cut wire piece for safety, while Tweakz® for Aligners features a diamond dental file to smooth out rough spots. Both of these tools have additional features designed to improve the patient experience and office efficiency.
Currently, patient goody bags seldom include tools to help with these common problems of wire breaks, sharp edges, and bracket problems. Including a tool to help patients handle broken wires and brackets at home in a hygienic fashion would yield substantial savings and empower patients. Furthermore, the clinic time saved by reducing emergency visits would allow a practice to take on more patients, increasing impact and revenue.
Empowering patients to resolve issues of discomfort at home – without the burden of additional, unscheduled visits – can improve the patient experience and improve orthodontic office efficiencies. As we learn more about the oral microbiome and the impact of orthodontic appliances, we may see additional health benefits with a rapid, self-manageable response to device breakage.
Oral Health welcomes this original article.
References
- Chow J, Cioffi I. Pain and orthodontic patient compliance: A clinical perspective. Semin Orthod. 2018;24(2):242-247. doi:10.1053/j.sodo.2018.04.006.
- Canadian Dental Association. Orthodontics at any age. Canadian Dental Association. Accessed June 27, 2023. https://www.cda-adc.ca/en/oral_health/procedures/orthodontics/
- Dewhirst FE, Chen T, Izard J, et al. The human oral microbiome. J Bacteriol. 2010;192(19):5002-5017. doi:10.1128/JB.00542-10.
- de Freitas AOA, Marquezan M, Nojima M da CG, Alviano DS, Maia LC. The influence of orthodontic fixed appliances on the oral microbiota: A systematic review. Dent Press J Orthod. 2014;19(2):46-55. doi:10.1590/2176-9451.19.2.046-055.oar.
- Lucchese A, Bondemark L, Marcolina M, Manuelli M. Changes in oral microbiota due to orthodontic appliances: a systematic review. J Oral Microbiol. 2018;10(1):1476645. doi:10.1080/20002297.2018.1476645.
- Mulimani P, Popowics T. Effect of orthodontic appliances on the oral environment and microbiome. Front Dent Med. 2022;3. Accessed June 27, 2023. https://www.frontiersin.org/articles/10.3389/fdmed.2022.924835
- Brown M, Wiltshire W, Henrique de Sa Leitao Pinheiro F, Schönwetter DJ. Adult patient preference for an orthodontic care provider in Canada. Am J Orthod Dentofac Orthop Off Publ Am Assoc Orthod Its Const Soc Am Board Orthod. 2022;162(4):477-482.e5. doi:10.1016/j.ajodo.2021.04.035.
- Bradley E, Shelton A, Hodge T, et al. Patient-reported experience and outcomes from orthodontic treatment. J Orthod. 2020;47(2):107-115. doi:10.1177/1465312520904377.
- Pachêco-Pereira C, Pereira JR, Dick BD, Perez A, Flores-Mir C. Factors associated with patient and parent satisfaction after orthodontic treatment: a systematic review. Am J Orthod Dentofac Orthop Off Publ Am Assoc Orthod Its Const Soc Am Board Orthod. 2015;148(4):652-659. doi:10.1016/j.ajodo.2015.04.039.
About the Author
Dr. Sima Yakoby Epstein, Founder and CEO of OrthoNu®, holds a Doctorate of Medicine in Dentistry and Clinical Orthodontics from University of Pennsylvania School of Dental Medicine. She completed her residency at New York Presbyterian and taught at New York University. She created OrthoNu® with a goal to support the emerging needs of orthodontists and their patients in a rapidly evolving landscape.
