Interview: “Adults offer exciting and rewarding challenges for the entire dental team”

Dental Tribune Online: A recent survey by the BOS has indicated that orthodontic treatment of adults is further on the rise throughout the UK. Is this finding accurate in your opinion?
Dr Robert Kirschen: The recent BOS survey on adult orthodontic treatment was not based on the objective collection of verifiable data, but sought the opinions of orthodontists. There seems to be a clear consensus that the number of adults receiving treatment in the UK is on the increase. It is difficult to be absolutely certain on the demographics, but a supporting observation is that it is now possible to have an adults-only private practice, whereas this would probably not have been possible ten or 15 years ago.

My opinion is that adult orthodontics in the UK has been increasing throughout the 36 years I have been practising, but this has been a gradual process rather than recent or sudden. The exception is the proliferation of quick-fix orthodontics in general dental practice.

What impact is this development going to have or has it already had on clinicians’ approach to treatment and treatment objectives in general?
Kirschen: While the rise in adult orthodontics presents opportunities, the impact will vary according to individual circumstances. As a specialist with a career-long passion for postgraduate training and ethical standards, it is disappointing to see that many of our general dental colleagues are being misled to believe that a one-day course is all that is needed before launching into providing fixed appliance or aligner therapy.

It is inevitable in my view that scant attention is given on such one-day courses to understanding the underlying causes of malocclusion or the long-term impact inadequate treatment can have on the occlusion or dental or periodontal health. In some cases, treatment may not be causing harm, but fails to progress (which I suppose is a form of harm). This may appear to be a harsh assessment, but it describes accurately the experience of unhappy patients that have ended up in my practice.

For orthodontists, the opportunities are mixed with elements of doubt, as very little training in adult orthodontics has been provided for the last ten years in Membership in Orthodontics specialist training programmes. Once qualified, much of the training available is offered by product manufacturers and therefore lacks objectivity and includes information on only one form of treatment. These observations constitute the rationale for our one-day course on adult orthodontics specifically for practising orthodontists.

What are some of the key aspects of the treatment of adult patients in your opinion?
Prof. Ama Johal: Assessment and treatment planning. These are very important. In paediatric orthodontics, patients start from different positions, but the aims of treatment are essentially the same: Class I with good function and good facial aesthetics. This is not necessarily so for adults, as the risk–benefit analysis or biological limitations or the unacceptability of some forms of treatment, or a host of other factors, may determine what kind of outcome can sensibly be achieved within a reasonable time frame. It is essential that the patient and clinician be on the same page.

Our presentation at the BOC conference will be mainly clinical and we will highlight our keys to excellence in adult orthodontics. There are seven keys, some of which are conceptual, such as truly accepting that every patient is different as described above, while others emphasise the need to develop clinical skills, such as using temporary anchorage devices or sectional mechanics, to deliver precise and predictable outcomes. Much effort in our practices goes into the provision of dependable long-term retention. This is very important to our patients, as well as for our reputation.

You say that treatment of adults has nothing or little to do with a cutting-edge mentality and more with doing simple things well. Could you elaborate on this concept?
Kirschen: Every field of activity has a cutting edge that is essential for progress. The cutting edge is where new ideas are tested and sometimes followed up, but often discarded. However, as explained to me by a management consultant, the cutting edge is where you cut yourself—which in his environment is referred to as the “bleeding edge”. This should not therefore be equated with using the latest gizmo or with a new fad. Out-of-the-box thinking and treatment may be appropriate in selected cases provided the patient is fully aware that treatment is not mainstream.

However, the raising of standards in a practice depends not on what happens to a few individuals, but on doing simple things better for all patients. Examples include analysing space and prescribing the most appropriate brackets for each patient, and minimising bracket and bonded retainer failures. The list is extensive, but the point to be made is that clinical excellence has more to do with attention to basics than with being in love with high-tech or slavishly following a philosophy for which there is no evidence (if there was evidence, it would not be a philosophy).

Management consultants define excellence in service industries as “getting it right first time, on time, every time”. How true this is!

There seem to be many exciting possibilities nowadays when working in a multidisciplinary environment. What would a case being treated by clinicians from various disciplines involve?
Johal: Adults offer exciting and rewarding challenges for the entire dental team. There is no doubt that patient expectations have risen and, in order to meet these, the orthodontist can be an integral part of the multidisciplinary care team and thus help deliver what otherwise may be considered undeliverable.

Effective three- or four-way communication is the key to these cases. Each extra person in the loop doubles the communication challenge and, in our experience, it is often the orthodontist who takes up the role of coordinator until the patient is ready for the restorative phase of treatment. The presentation will provide a range of multidisciplinary restorative care options achievable with this approach.

What else can attendees of your BOC lecture look forward to?
Kirschen: Clinical tips. All clinicians enjoy them. Some of these are mine, but I also use many clinical tips picked up over the years and I know exactly where each one came from. We also aim to give hope, as our message is that excellence is within reach for all orthodontists who accept that the secret is to do simple things well and consistently.

Thank you very much for the interview.