Pacific Coast Society of Orthodontists Bulletin Summer 2020 - 74

Practice Management

Practice Management Diary

When Does an "Essential"
Orthodontic Procedure Become
"Urgent"?

Dr. Jeffrey Nichelini
American Canyon, CA

74	

On March 15, 2020, the California Dental Association recommended that dentists limit their
practices to only essential and urgent procedures to help contain the spread of COVID-19.
This recommendation provides a lot of room for
interpretation. On one hand, the vast majority of
orthodontic patients can have their appointment
intervals delayed by a few weeks without causing
irreparable harm to their dentition. On the other
hand, close supervision of active patients is
necessary to ensure that untoward effects do not
develop. Following the release of this recommendation, my initial thought was to cancel all new
patients, proceed with business as usual for my
active patients, but extend appointment intervals
to lay the foundation of a slower office that could
respect social distancing guidelines. Apparently,
this approach was too conservative. Twenty-four
hours later, after texts from my local colleagues
and emails from members of my disability group,
all of whom had implemented the recommendation more aggressively, I effectively shut down my
office. Coincidentally, on March 16, the American
Dental Association released their first recommendation, which eliminated the word essential and
indicated only urgent dental procedures should
be completed. This recommendation took an
added step of outlining the types of procedures
that should be considered urgent for various specialties, including orthodontics, and listed sources
of ulceration (ie, poking wires) as the only urgent
orthodontic concern. In my humble opinion,
orthodontists have many urgent concerns beyond
poking wires, and I am curious about the origins
of this recommendation. The American Association of Orthodontists provided guidance to its
members in a March 31 e-mail. It advised following all applicable government recommendations,
and defined emergency orthodontic care as "care
that will relieve pain and/or infection, is trauma-related, or is critically necessary to prevent
harm to the patient." This recommendation is

very sensible, and it would be hard to argue that
the typical orthodontic adjustments should be
considered an urgent concern; but taking a broad
look at a busy practice's patient base, even if it is
not likely that an individual will develop a major
problem by delaying their routine appointment
by a few weeks, among several hundred active
patients there is a good chance that a few will
develop issues that should have been addressed
sooner.
Three weeks into quarantine (the draft for this
article is due April 8), I can't help but dwell on the
ethical principle on nonmaleficence, under which
the concept of patient abandonment is outlined.
Interarch springs for Class II correction can overcorrect. What happens if a patient overcorrects
to end-on anterior occlusion and fractures an
incisor? Uprighting the second molars is already
a delicate procedure. What happens if a tooth
with compromised periodontal support moves
into hyperocclusion for several weeks? Temporary
anchorage devices can become mobile but not
painful. What happens if an infection develops
and spreads? Even mundane issues with bracket
placement, nickel-titanium wires, and elastomeric chains can cause problems if left unattended.
Lower incisors can rotate in a few days without
retention. Are retainer checks an essential or
urgent orthodontic procedure?
At the time of this writing, the Napa County shelter-in-place order has been extended from April 7
to April 30, which will be six weeks of quarantine.
After this date, I suspect the point will be reached
at which routine orthodontic biomechanics are at
risk for causing patients harm and thus routine
orthodontic adjustment visits should be considered urgent dental care. I can't say with certainty
that I intend to reopen my practice by then, but I
will commiserate with the rest of the orthodontic
community by stating I sure hope that I can.

PCSO Bulletin    Summer 2020



Pacific Coast Society of Orthodontists Bulletin Summer 2020

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