Ortho Q & A with Dr Liz Fisher Part 1

Are You Referring Your Ortho Cases Too Late? 

In this episode of the Correct Dentistry Podcast, Dr Jill Fisher is joined by her sister, specialist orthodontist Dr Liz Fisher, for an insightful conversation on orthodontics. 

 From the differences in compliance between 12-year-old girls and boys to the post-COVID boom in adult braces, there’s so much to unpack. 

Plus, Liz shares invaluable insights on when to refer young patients for early intervention. 

Visit this link to download your copy of the Australian Orthodontic Society "When to refer" handout.  A must for every general dentist. LINK

Like to learn more about Correct Dentistry ? visit correctdentistry.com.au 

This podcast is brought to you by CORRECT DENTISTRY

Transcript

Dr Jill Fisher 0:09

Welcome back to the Correct Dentistry Podcast. And today's an exciting day for me because I get to interview my sister Liz. So this is Liz Fisher. She's a partner, owner of Brisbane Orthodontics, which is Brisbane's oldest orthodontic group practice. And we're here to talk everything orthodontics and help the general dental population really understand what we need to know about referral-based orthodontics. So, Liz, introduce yourself and let us know why you became an orthodontist.

Dr Liz Fisher 0:42

Thank you for having me, Jill, and by extension, Michael. I'm Jill's little sister. We grew up in a family of dentistry, so it seems to run in our veins. But if you'd asked me what I would have done when I was in grade 12, the only thing I knew was that I didn't want to be a dentist. And here we are. I think I ended up being an orthodontist because general dentistry wasn't for me. I enjoyed my training immensely, but the actual day-to-day practice of general dentistry I didn't enjoy. And I think a big part of that was that I felt like I could never know enough about multiple areas. And I really just wanted to know everything I could about one little area. And I really enjoyed treating kids, so I ended up going into orthodontics.

Dr Jill Fisher 1:23

Yeah. And so with your day-to-day job, I know some orthodontists are have really specific things that they like to treat. Some only treat kids, some treat lots of early intervention stuff, some people like adult patients. Do you think all orthodontists see all patients, or do you have a real niche that you like to work in?

Dr Liz Fisher 1:45

I think most orthodontists these days will see a big range of patients. And I think particularly in capital cities, you have to do that. I know in regions some people can really limit their practices to only seeing kids. And some people really enjoy doing the more difficult, multidisciplinary adult patients. But for me, I like a mix. If my day was full of 12-year-old girls, it's probably an easy day. If I've got a day full of complex adults, it's a more difficult day, but they can also be the most rewarding patients.

Dr Jill Fisher 2:18

So I'm I mean I find 12-year-old girls terrifying. Why are they easier than 12-year-old boys?

Dr Liz Fisher 2:23

12-year-old girls are great because they are all keen for orthodontics these days. It's rare that I have to convince a 12-year-old girl to go through with the treatment. They tend to be very compliant, their oral hygiene tends to be good, and I get on with them well. And so we we can develop a nice relationship over the course of us seeing each other.

Dr Jill Fisher 2:44

And have you found in your career that the more kids you treat, the more adults of those children then tack on to the end of that treatment? 100%.

Dr Liz Fisher 2:52

We treat so many parents of the kids that we saw, we we see, and we saw a huge boom in adult orthodontics after COVID, which was really interesting. You know, for a lot of us, obviously all of us in dentistry, COVID was a very interesting time. Um, and we wondered what would happen to our practice post-COVID, but in fact we got so many adults, people that we'd done consults on years previously, that were coming out of the woodwork wanting their treatment. And I think a lot of that was probably being on Zoom meetings and those sorts of things. People were spending a lot of time looking at themselves.

Dr Jill Fisher 3:25

Oh, that's classic. Um, and so do you find the adult ortho patient is a more challenging clinical Almost always.

Dr Liz Fisher 3:36

Almost always. And um, you know, with adults there comes a lot of previous dentistry, which can make our job more challenging, things like implants, bridges, um, more ceramic surfaces for us to be bonding to. Um periodontal disease is a huge part of what makes it more challenging. Um, and also I think adults generally uh we run into more issues with unrealistic expectations about um their aesthetic outcomes and uh and also they want it done twice as fast as their kids' treatment. And it's much more in general more unpredictable to treat adults than it is kids.

Dr Jill Fisher 4:15

Are they wanting Invisalign or Clear Aligners over fixed braces, or are you seeing a big mix?

Dr Liz Fisher 4:21

It's more of a mix these days. There was a big uh time where Invisalign or Clear Aligners was the only option adults would go for, and we had to really convince them to use fixed appliances in cases where we thought that would be more advantageous. But um I'm finding the more people that know family members and social acquaintances that have been through a liner treatment, they realize it's not an easy way out. And so it's very interesting that now we're finding a lot of people coming in actually asking for braces. And sometimes it's not the right option. So sometimes these days I'm actually convincing people to have clear aligners in certain situations.

Dr Jill Fisher 4:59

I mean, as you know well, I had braces in my 40th year, um, and you did my braces, and I found it to be quite an excellent experience. I know myself well enough to know clear aligners would not have worked for me. I would have been a non-compliant, frustrating patient for you to deal with. So um, but you spoke before about you convincing patients to do or trying to educate patients in one way or the other because certain um cases lean in one direction. So is it still true that Invisalign can't be used for everything, or is it is yeah, yeah.

Dr Liz Fisher 5:34

Yeah, it is in in my hands at least, and you will f always find uh key opinion leaders who will say that you can treat everything with everything. Um, however, in my hands and most of my colleagues, I would dare say there are certain cases that we would still much prefer to treat in fixed appliances. Having said that, these days, you know, there's patients such as patients with a lot of ceramic surfaces, patients with um ongoing periodontal maintenance therapy, uh, which means oral hygiene is very easy with aligners, patients that tend to be more open bite rather than deep bite. These are the patients that I go, you'd be a great in-design patient, as long as the person on the other end of the aligners is doing what they need to do. So, you know, my girls at work will hear me say very frequently, it's you're either the sort of person that will wear aligners or you're not. And you've got either got the lifestyle that will suit your aligners or not. And if you don't think you're either of those ones, it can be an enormous waste of time, money, emotional energy, and you're much better off doing fixed braces or indeed not doing orthodontics. You know, orthodontics in general is not for every adult patient.

Dr Jill Fisher 6:43

Yeah. Uh and how often are you starting in Visaline and ending in brackets? Very rarely these days.

Dr Liz Fisher 6:49

Very rarely. Um, it used to be quite a big part of our practice. Um, in fact, there would be cases that I planned that way. These days, if I'm planning a hybrid approach, I often start in brackets if uh if there's a particular movement that I want to unravel or a rotation or something that I'd like to get out first, then I'll do that. However, it's not, it's a rarity these days.

Dr Jill Fisher 7:11

So I want to switch back from talking about adults in also back to our general children patients that we see, pediatric patients that we're seeing in general dental practice, and when you want us to refer. I know a lot on social media there's all of this stuff about early intervention. There's a lot of chat from on forums about children being treated early. I've always struggled with knowing exactly when you want to see the patient and exactly what you want from me. I have the advantage of flicking you a text in between patients and knowing you're going to give me the answer, but not everyone has that, has you as their resource. So what do you want from the general dentist who's referring you a patient?

Dr Liz Fisher 7:55

Yeah, so I think firstly on that, I think trying to build a relationship with your favoured specialist is great because then you can give really quick opinions on uh things that will then mean that perhaps that parent doesn't have to take a bit of time off work to bring their kid in for me to say, I'll see you in 12 months, or um or for the general dentist to learn something so that they can reassure the parent that that's okay and and losers had a look at it. So I think fostering those relationships is really uh can be really important. I would say in it as a general rule, earlier rather than later. So because there's apart from you know a nominal consultation fee and a bit of time away from work or school, you know, you haven't lost anything by seeing that patient early and starting a relationship early with an orthodontist. So early intervention orthodontics is something that we all do to some extent. There's just a huge spectrum of of how often or how eager certain practitioners are to do early intervention, and that can depend on their philosophy, where they trained, all sorts of things. So there are certain things that I routinely treat early. Um and you know, I do like to see those things early. As a general rule, there is a fantastic resource put out by the Australian Society of Orthodonists that I every time I speak, I recommend people print it out and laminate it and put in their office. Because if you're not seeing kids all day, every day, um, these sorts of things at appropriate ages might not be front of mind for you. And so I think it's particularly for new grads, a fantastic thing to have in their office. And that's freely available at the Australian Orthodonic website. Um, and I would encourage you all to print it out and have a look at it.

Dr Jill Fisher 9:44

Well, we'll get that resource and we'll put it in the show notes for today's podcast so you can all access it. Um, that that answer to that question has given me a few more questions. So when you said there are a few things that you do treat early, can you dot point them for us?

Dr Liz Fisher 9:58

Yeah. So basically the things I'm looking at treating early are things that from a purely functional point of view, um, if I don't do something now, will it cause damage if I wait? So things like anterior crossbites leading to wear on teeth or possibly recession on lower incise as a result of that crossbite. That's a no-brainer, I treat that all the time. Um things like uh posterior crossbites with mandibular shifts, I treat that really routinely. Um, the other side of this is not so much the functional uh side of things, but the psychosocial part of our treatment, which is a huge part of orthodontics. So the kids that are embarrassed by the teeth, someone's making comments at school, those sorts of things. I have the conversation with the parents that I say there is no functional need to treat this, but if it is affecting your child's experience at school and that sort of thing, then absolutely we can often do something to tidy things up. Um, what I always like to stress to the parents is usually, and not always, but usually early intervention is a first phase of two phases of orthodontics. So it's really important that the parent understands that so they don't think that this early sort of generally quick treatment will mean they never need any future treatment down the track.

Dr Jill Fisher 11:17

Okay. Um and as far as general dentists go, what are we looking to recognize other than those things? I mean, what I'm getting at is one of your lovely colleagues, Dr. Andrew Mackenzie, I listened to him speak a while ago and he said this statement that is burrowed into my brain and has never gone. And he said, the best gift you can give a 10-year-old child for their birthday is to palpate for their upper threes. And I thought, well, I haven't been doing that. Absolutely. And so that's a really great one for me. I haven't forgotten it. I do it every time. So do you have any other pearls of wisdom like that? And going back to the upper canines, if we can't palpate them, what do we do? Are we referring straight on? Are we imaging? Are we waiting another six months? What do we do?

Dr Liz Fisher 12:06

So I'll answer the first part of that question to start with. So uh what you're looking at in each patient depends how old they are. And that's where that sheet from the for the ASO is really good because it breaks it down by dental ages. And what should you be looking at at that stage? So the classic thing is, you know, you've got your six-year-old in that's starting to get there, six-year-old molars and they're incisors, and things you're looking at there are hypermineralization of molars. Impacted first molars is a huge one that is often missed and should at least get some advice, if not intervention. Um, crossbites developing with those front teeth, and then you go through to sort of eight to ten-year-olds where you're looking at um big malocclusions, so the the big class twos or the big class threes. Class threes are ones that we really want to see early because there are interventions that can be done reliably between eight and ten. Um, that again you may not do it, but at least the conversation should be had. Class twos is a different kettle of fish, but there are opportunities for intervention early if we want them. Canines is a huge one. So that that idea of giving the 10-year-old the birth the birthday present of palpating and canine is perfect because um impacted canines are something we treat every single day of the week. And the ones that almost always have the best outcomes are the ones that were discovered early. Um and so uh you can really make a massive difference to that kid's dental future if you can just run your finger up in the buccal sulcus around that age. Having said that, you really need to look at the dental age of your patient, not just the chronological age, because I see plenty of 10-year-olds that are in full permanent dentition and they probably need the pated the palpation at eight. Um so it's it's always really important to think about that. If you don't feel a canine, it doesn't necessarily mean there's something wrong. But if you don't feel a canine, I would take an OPG, it's the first thing. Um and if it looks normal on the OPG, and by that I mean it doesn't look significantly wider or narrower than the contralateral one, if it's not crossing the root of the lateral incisor, I'd give it time. Um or flick it to your friendly orthodontist and say, You're worried about this, I can't palpate that canine. If on the OPG it looks at all abnormal, refer it. The most common early intervention for that is going to be an extraction of a deciduous canine. And it's if you catch it at the right time, this is for palatally impacted canines, I should stress, but for palatally impacted canines, if you can extract that deciduous canine at the right time, it can greatly improve the trajectory of that tooth. So it's a really, really fantastic early intervention.

Dr Jill Fisher 14:55

And I remember Dr. McKenzie talking about the degree of crossover of that lateral being really suggestive of success. What are what are those numbers look like?

Dr Liz Fisher 15:05

So um there's a few different ways of categorizing impacted canines, but one of the classic ones is is by Ericsson and Currol, which which goes back to the 70s. And basically it divides the root of the lateral into quadrants. Um if your canine isn't crossing the root of the lateral, then it's got a very, very high success rate. Once it crosses midway, it's starting to get dicey. But if that's my child, I am still extracting that deciduous canine in the mixed dentition because I think you've still got a chance, even if it's not fully successful, that it will at least improve its position, which means that further intervention may be helpful and you may be able to avoid surgical exposure and bonding. We do surgical exposure and bonding every single day in our practice. But treating a lot of those kids, if I can avoid that for one of my patients, I definitely would like to do that. And at what age is the best age for the surgical exposure then? Generally speaking, we'll try and delay that until we can get into uh sort of leg mix permanent dentition. So you want to be able to try and do comprehensive treatment while the exposure and bonding has happened. Having said that, if there's damage to the lateral, you may not have that later. And sometimes we do expose it early and just with the pure uh goal to take it away from the um lateral incisor.

Dr Jill Fisher 16:32

So I suppose the only other thing that I I note as being potentially dangerous as far as misdiagnosis or um or not non-diagnosis is the problem of the hypomineralized six. And I know that's what you're here today to lecture about, and I've uh uh whispered you away just to have a quick chat. But can you talk to us about the significance of the hypomineralised six um and your best quick summary of treatment options?

Dr Liz Fisher 17:04

So it is such a common, common um problem that we see in kids. Um, and I think, you know, with as a parent myself and as a practitioner, I think information is power for the parent of that child. So um I think if you can identify the hyperminalisation early, which you should be doing when that child is six or seven, then you have more options on the table. From an orthodontic perspective, I would always want to be involved in any decisions that are being made about that hypermineralized six. So before it goes to have a stainless steel crown on it, or before it gets extracted, I would really love to have the opportunity to chat to that parent and the treating practitioner about what to do with it. But essentially, you know, from my point of view, the option is are we maintaining that tooth or are we extracting it and using that space or having to close that space in an orthodontic um capacity? And uh, you know, I am speaking for an hour on this topic today at Tim's course, so it's very difficult to just still it down into um into a snapshot or a or a sound bite. But the bottom line is every single one of those kids is different, and you've got to have a multidisciplinary approach, I believe, in order to give the parents and the kid the best uh understanding of what their future might hold.

Dr Jill Fisher 18:29

So recognize and refer. Look, Liz, I I actually have so many more questions. So we're gonna break here and we're gonna come back for part two of this podcast with Dr. Liz Fisher from Brisbane Orthodontics. So please come back for part two.