hey it's dr amanda from smile solutions street smile solutions.com
and today i'm going to be talking about mobility in teeth during orthodontics doesn't matter if
you're doing braces or aligners unfortunately it's one of those things that can happen but
let's talk about the why behind it and how to prevent it and this video as you know if you've
watched my videos before um there are some are more consumer facing you know at that level and
some are more doctor facing this one is going to be more doctor-facing although if you are
a consumer and you want to learn about this you can take this information to your doctor
because if your doctor is an orthodontist your doctor understands this if your doctor is a
general or pediatric dentist or any other type of dentist they may not fully understand this so
this video might be helpful for them to help to solve the mystery of why a tooth is loose
so first of all doctors you need to make sure your patients are signing their informed consents
there is a section in every informed consent it doesn't matter if it's clear correct invisalign
a branded informed consent for aligners um hopefully if you're doing off label or white
label aligners you've created your own informed consent if you haven't we do have those on sale at
our document store at straightsmilesolutions.com um if you're doing braces you should have your
own informed consent there's plenty that are out there again that's something we also have in our
document store so start there if you did not have your patient sign your inform consent stop don't
listen to this video anymore call your tdic or aoic and you know exactly what i'm talking about
and get this problem solved because you've got a problem i'm just gonna leave it there and not
tell you anything else okay next let's find out why so first you gotta play detective to find out
why you have mobility on a tooth it doesn't just i mean occasionally it could be iatrogenic and
we don't know why it happened and that's covered in the informed consent but most of the time it's
caused by something i'm not going to say something you did wrong but something went wrong and i'm
gonna list off all the different things that could have gone wrong um and now whether or not who's to
blame for it who's liable for it will depend on how you handle it from here on out and again i'm
just going to give you clinical recommendations on what it might be if it's a big problem you
really should contact your risk management company make sure you have things taken care of
we do help doctors at straight smile solutions develop ideal treatment plans and learn how to
do things more correctly more correctly correctly so hopefully these type of things don't happen but
sometimes they do okay and again it goes back to the whole iatrogenic thing it can happen
that's why we sign informed consent that's why we monitor patients during treatment and mobility is
one of the things you should be monitoring during treatment because it happens and when it happens
you need to think about why it happens and make corrective changes so that it can get better
okay so detective time what things i check so when a doctor comes to me and says hey my patient has a
has a loose tooth during braces what should i do first thing i'm going to say is okay this is
what i need from you um doesn't matter if it's a braces or a liners patient i need a full set
ortho 8 series of photos um current of where they are now you know the regular ortho photos and
i also need a full set of photos from the start and hopefully you have these you should be taking
regular progress pictures throughout treatment i would say definitely every six months to a year is
standard of care um and of course if you're having a problem you take progress pictures immediately
as soon as the problem arises and document so i'm going to ask for that i'm also going to ask for
current x-ray take a pa of the affected area as well as the start x-rays okay so these are
the things that you require from doctors when they come to me with one of these problems in addition
if the patient is an adult i'm going to ask for period probings and charting um as well as initial
and progress so you're going to have to do probings of the affected area or spot programs
i'm going to want to see that so x-rays photos initial and progress initial in progress okay
so i know it's a lot if the patient is in aligners i'm going to want to also see tracking pictures if
you don't know what tracking photos are you got a lot to learn so you should definitely read my
book would be my suggestion if you want to read my book it is probably the best 9.99 if you do
kindle that you've ever spent otherwise it's 49. you can get it at amazon in the textbook store um
if you go to my website straightsmilesolutions.com it's prominently right on the banner can't miss
it so and i often give out free copies on my webinars um if you're going to ada this fall 2021
in las vegas i'll be giving out some free signed copies there as well all right so and also my
youtube channel has over a thousand videos my gpwebinar.com channel has about 10 videos that are
all really helpful there's so much information in there and that's all free so feel free to enjoy it
and that's my quote free courses um okay so we've got all the diagnostics so we're going to look
over the diagnostics for a liner patients we're also going to want to see their quote-unquote clin
check clear pilot treatment plan the animation because the first thing i'm going to do is see
that animation is makes sense i mean is it a realistic animation or is it way too aggressive
um if you have a moderate to severe crowning case i'm probably gonna also recommend a seth
if you didn't take one at the beginning go take one now this is where you gotta take
one because we gotta see the position of the lower incisors don't freak out on seth's i have
a ton of videos on how to get cephs and how to obtain seth's even if you don't have a seth arm
if you are if you don't can't do a ceph you can always do a cbct just of that area mostly
i want to look at the incisors you know like a lateral position of it and take a slice of that
you may not be able to get the numbers that way unless you have the whole step as for reference
um but there's a lot of stuff we can see just from that slice just with my trained eyeballs
and stuff like that but you might be able to send it to i usually use safex but a lot of ortholabs
i have videos on this too so anything that i'm mentioning that you don't know
you can email us at info streetsmilesolutions.com or message us at straightsmilesolutions.com say
hey can i get your stuff videos we'll send them to you no problem free just let us know what you need
or you mentioned something about how to get steps if you don't have a staff machine just message us
and we'll send it to you because i know where all my content is and i can get it for you in
like five seconds it's really easy i don't mind at all just message me and i'll send it to you
you need that stuff if you're getting mobility you need a ceph that would be considered standard of
care if you didn't take one at the beginning it's okay fine take one now and let's that's gonna help
solve the puzzle piece as to what is wrong so we're going to take all that data and we're
going to sit down together and we're going to find out what the problem is was it the treatment plan
was the treatment plan too aggressive it's top three reasons it's often the treatment plan
if it is a a liner case i look at these treatment plants i'm like that's way too
aggressive of course it's going to get loose because it's too fast it doesn't have time to
stabilize the osteoclasts and osteoblasts don't have time to rest listen i love invisalign and
clear correct there's a lot of in a lot of aligner companies but people don't understand when you
it's basic ortho moving teeth with slow and low and gradual forces is healthier for the
teeth and bone you're going to have less side effects less discomfort less mobility
better outcomes and actually it's going to get done quicker than it would if you moved it fast
yes overhead might be a little more expensive but not if you're doing
invisalign comprehensive or clear correct unlimited because it doesn't cost you anymore
to do it slow on though you just have to ask for it if you don't ask for it you don't get it
so that is one of the top three reasons that you get that too aggressive of a treatment plan real
easy take your records figure out what happened if that's what it is we're just going to modify it
and we are going to slow down the movement so things have time to stabilize um number
two reason might be again this is where the stuff comes in did you try to invade the biologic width
that's ortho terms for did you you know if if you take a ceph you can look and get your
your angle of the incisors to either the maxilla or the mandible and that tells you
is it safe for you to flare those teeth forward anymore remember invisalign and clearcorrect
one of the main ways they eliminate crowding we've talked about how to deal with crowding is
expansion and proclination nothing wrong with that if you got a healthy patient with a lot
of bone but lots of things wrong with that if you don't have a healthy patient with lots of
bone and invisalign and clear crack technicians have no idea because they don't have your cef
and they don't have your period charting and they don't have your cbct and they don't have all the
data they're just doing what you tell them to do so they very well might invade the biologic
width with their treatment plan and you as the doctor are supposed to tell them no don't do that
or yes okay to do that if you don't tell them you might have a treatment plan that's causing
loose teeth again who's responsible ultimately if this comes to the dental board or if this
comes to a complaint with the insurance company who's responsible you are the doctor you are the
doctor you're responsible you're the liable one because you didn't make a good treatment plan
you cannot rely on these treatment planners at these companies to tell you what to do that is the
biggest mistake you can do you will get sued and you rightfully honestly should get sued for making
bad clinical decisions for jumping into specialty work without knowing what you're doing i'm sorry
but there's a reason why orthodontists go to residency for three more years i'm not saying we
don't make mistakes because we do but we don't make these kind of mistakes on a regular basis
and these are like top three mistakes that general dentists make every single day so i i know some of
you can get freaked out listening to this but it's really really easy to go through your treatment
plans to go through all your cases and say have someone who's an expert whether it's myself
whether it's one of many other orthodontists that do this for a living treatment planning
services i mean there's ones i recommend and i have a lot of competitors who i think are awesome
you know there's more there's over 250 000 primary care dentists just in north america alone you know
and most of them are doing ortho i'm not concerned about a little competition because i think
you guys need us you know if we can prevent patients from having loose teeth it's worth it
right i will be glad to impart some of my wisdom on you okay so we talked about bad treatment
plans we talked about aggressive treatment plans unpredictable treatment plans what else could it
be well i do have another video that talks about yeah invading the biologic width we talked about
that pushing things too far forward let's talk about patients with existing periodontal disease
you know low crown derivative ratio etc if your patient has periodontal disease to begin with
well don't push the teeth forward and one of the biggest mistakes you can make is round tripping
i don't round trip in periodontal patients nope so you need to learn and you're going to most likely
in periodontal patients want to incorporate ipr into your treatment plan a lot of it
you know and or lower in size of extraction would be another option since usually the teeth they get
most loose are the front teeth right so you need to really think about this and do a regular if
you have a fair amount of of crown jewelry ratio attachment loss should you even be doing ortho in
this patient i always recommend in this case that you get the perio managed first and if it seems
kind of sketchy the amount of attachment loss that's already lost you really should send that
patient to a periodontist to start i realized that you'd like to manage your own payroll and
keep that in-house but the liabilities also on you there are periodontists for a reason
they are out there to make sure bone and tissue stays healthy and they would be more than glad
to manage your patient during that period of orthodontic treatment let them clear the patient
to start let them management the liability is now off you if they're managing it you know and they
can tell you to go stop slow down whatever they need to do and you can take all the pressure off
you i think it's the smartest thing to do just like i recommend when there's resorption to work
with the endodontist the specialists are there for a reason don't always keep everything in-house
because you're also keeping all the liability in-house if and when things occur right okay
next so those are the top three that we talked about just existing periodontal not
incorporating enough ipr not taking the right diagnostic records not doing the most right
progress records um aggressive treatment plans to fast treatment plans um yeah again invading
the biologic with some things like that so what to do often involves a change in treatment plan
might add more ipr take additional diagnostic records make modifications um you also need to
quantify the amount of mobility now remember you're taking a tooth which is a living
structure and you're dragging it through bone which is you know it could be more dense in some
patients less dance in other patients it's also a living structure that needs to remodel of course
it's gonna get a little bit loose one millimeter remember you have to go back to your dental school
let's quantify mobility um one low mobility fine one plus probably also fine two
not fine two plus not fine depressible not fine so you need to keep an eye on areas of
insights that are mobile you need to slow down your treatment plan slow down your mechanics
sometimes you're gonna have to stop treatment if there's really no if any other way around it you
know without making it worse i mean if you can't find anything to help it or to change it you might
need to stop treatment we call that discontinuing and that is also built into again hopefully you
had your informed consent signed that's built in there it says in their language that sometimes we
have to stop treatment early sometimes we don't finish the treatment this is where you need to go
back to your contract and if you didn't watch my lecture last week and i did with miss bonzi popat
who is an expert at contracts and um management and insurance for ortho you should definitely
watch it because there was a lot of great pearls in there about contracts and she even
has templates for contracts that she'll be glad to give to anyone who is one of her clients and you
can book a session from my website if you go to my website and go to classes look for the classes
by fancy popat very reasonable prices too by the way for the amount of money it's going to save you
and you want to make sure that you have that built into your ortho contract and i do have contracts
by the way in my store if you want to go there but it doesn't necessarily have all this stuff built
into it it's a real vanilla contract so i would recommend working with bonzi on your contract
because she can build things like this into your contract and give you suggestions on the verbiage
but the main thing is that you want to have an out so if if we got mobility of two plus on number
24 and we've already optimized the treatment plan and then and we've there's no other way to do this
it's you have to do no harm first and you've got to talk to the patient say i'm sorry i know you
want to keep going and making this straight but in doing so our likelihood of this tooth falling out
and not surviving is high and an implant is a lot more expensive than leaving it slightly crooked
so i'm just going to take this tooth out of occlusion and we're going to finish up
the top teeth and then be done and leave the bottom teeth a little bit crooked it happens
yes sometimes you might have to give a partial refund this should all be built into your contract
if you need to discontinue early on how that looks like if you don't have it built into your contract
you need to meet with bonzi and figure out how to do this because you're going to be so much happier
if you have this all built into your contract so when these one-offs happen you are protected and
you don't have to give a full refund and you don't have to worry about complaints because
you're completely covered again contact your risk management company for your ortho
tips because these things happen so yeah i mean pretty much it i mean just change the treatment
plan slow down the movements and or discontinue at the end of treatment if you have a tooth usually
i love the idea with the liners of doing passable liners at the end just to kind of stabilize things
um but you can also consider something like custom bonded retention you know you can watch
all my videos on bonded retainers again you can't just slap these on in your office you
should have these custom made by a lab because when they're done improperly it's actually worse
than having no retention because all kind of wacky things happen not to mention you know
breakage decay calculus periodontal disease etc if they're not managed and remember if you bond
it you married it so if you bought a bonded retainer you're married to that patient for
life and you need to figure out how it's going to work with warranties breakage monitoring you
can build that all into the agreement and how it works and again bonzi pullpot is a great
reference for how to deal with this kind of stuff and that is also in our video which is archived
if you go to my gpwebner.com or if you go to um if you go to my youtube channel it's prominent
it's right there on the home page so hopefully this was helpful in terms of management and
how to avoid mobile teeth thank you so much any questions please go to streetsmilesolutions.com