Ortho Q & A with Dr Liz Fisher Part 2

 Have you ever wondered if early orthodontic referrals really make a difference? 

In our latest episode, our host, Dr Jill Fisher chats with her sister, specialist orthodontist, Dr Liz Fisher about why timely referrals can transform a child's dental journey. Many parents hesitate about tooth extractions, but understanding the right time to act can save future complications. 

Knowledge is power. By staying informed, we can make the best decisions for our patients.

What has your experience been with orthodontic referrals? 

Share this with someone who needs to hear this! 

This podcast is brought to you by CORRECT DENTISTRY

Transcript

Dr Jill Fisher 0:01

Welcome back to the Correct Dentistry podcast for part two of my discussion with Liz Fisher, orthodontist, and my sister. Welcome back, Liz. Thanks, Jill. So we finished part one speaking about the hypermineralised molar. And you know, you you mentioned it is such a big topic. So I don't um I don't expect to understand it fully at the end of this chat. But um basically the advice was if you see a child with hypermineralized molars, they need to get a specialist opinion. What about the children that didn't have any intervention when they were kids? They had the treatment on the molar, and now you're meeting them as an adult patient, and that tooth is failing or f or has failed, and you see there's a couple more molars in a similar boat in their mouth. Are we then getting an orthodontic opinion or has that ship sailed and now we're looking at replacing a tooth?

SPEAKER_01 0:56

I think in the absence of other orthodontic concerns, most likely you're looking at replacing a tooth. And, you know, that's that's okay. We're not here to demonize replacement of teeth. I just think it's important when the opportunity is still there to possibly avoid the need for that in someone's future. But once you have got to that point where that ship has sailed, if they have no other orthodontic concerns, there is no other reason to to undergo orthodontics, then yes, you'll you're looking at replacing the tooth. Closing a molar space in an adult is difficult at the best of times. It can be done in very specific circumstances on a very specific patient because it is not a quick and easy exercise. Um so most adults in that scenario, I'm talking three years of fixed orthodontics. And there's not too many adults that will come to you and and be happy to go through that.

Dr Jill Fisher 1:48

Yeah. Can you get there if they're really motivated, or are there some instances where you just still can't get there?

SPEAKER_01 1:53

There's some instances where it's you just cannot get there, or it or you are um on a cost-benefit analysis, it doesn't make sense to do so. Um, because in most cases, if you're trying to close a unilateral molar space, there's going to be um most likely, it's it's hard to talk in generalities, but but an author or an occlusal compromise for the for you having done that. So whilst the space may be able to be closed in isolation, what is that space closure doing to the rest of the occlusion while you're doing that?

Dr Jill Fisher 2:24

Right. I think this is the problem being a general dentist who doesn't do a lot of author and have a great understanding of it, and obviously you've got a specialist level of understanding and a lot of experience. But there's so many of these things that if you weren't my sister and I wasn't having conversations with you like this all the time, I wouldn't know that that was hard. You know, I remember when I was a hygienist in another life working for an orthodontist, and he said, Oh, hate when dentists send me this stuff, I just can't do it. And the reality is that dentist wouldn't have known that. Um, and it's really tough for us as referring dentists because I think we're doing what we're doing in good faith, but but we don't understand the movements. And listening to you speak just now in in Tim Key's course, you mentioned other instances where, well, oh, I could do it, but it would be really tough. And I don't like doing these things in specific bites, you know, a deep bite case moving specific teeth. And and they're things that we just don't learn in the undergraduate setting, so we don't know them. Um so I think what I'm understanding your point being is refer early, refer often, get opinions where you're not sure.

SPEAKER_01 3:31

Yeah, and I say that not for um self-congratulatory um uh advice or anything like that, and and not to garner referrals, but because it's in the best interest of your patient. Um and I do think uh even if they don't end up doing orthodontic treatment or um or replacing a tooth, you know, as I think I said earlier, knowledge is power. And if you can provide that that patient with all their options, then you've done your job. Even if you don't end up putting a bracket on that tooth, you've done, you've played an important role in the care of that patient, I think.

Dr Jill Fisher 4:07

And I suppose the early referral gives the parent and the patient time to understand what's coming up and a little bit of time to save up the money or digest the facts that are coming.

SPEAKER_01 4:18

Correct. And I think one of the more interesting spaces that we're going to certainly see more of are those kids that are somewhere between the two instances that you've spoken about, like the early intervention extraction of a compromise molar and the adult that's got a failing six. The the really interesting middle ground there are the kids that have probably missed the boat um for uh mesial migration of sevens, but perhaps will be setting themselves up nicely for an autotransplant. And that's an area that I think all of us will be seeing more and more throughout our careers and is is now, I think, should be a good uh and um uh and standard option discussed in suitable cases.

Dr Jill Fisher 5:01

It's an exciting space. Tim and I had a great chat about that. So if you want to look up that chat, have a look at the conversation I had with Tim on the pod. Um other things that I've noticed that have changed in the time that I've been a dentist, or even just looking back to when we were little kids at school and what our friends were having done, is there used to be a lot of extractions in also, and I sense that we're seeing less. Is that real? And and why is that? Is that parental pressure? Is it that techniques have changed, understanding has changed? Where has it come from?

SPEAKER_01 5:33

Oh, it's a it's a a lot of things. Um, you know, compared to say the 80s, where extraction rates were huge in orthodontics, it's certainly dropped since then. Um, but I don't think you'll find many orthodontists that will say I never extract a tooth, because what hasn't changed over the last few decades is human biology. And that's still what we're dealing with at the end of the day. There is certainly a great deal of parental pressure, which I completely understand to avoid taking out virgin unrestored teeth. I get it, I really do. But in some cases, it is absolutely the right thing to do. I think the latest rates of extractions in private orthodontic practice in Australia are somewhere, sit somewhere between 10 and 20%, which I think of cases, which I think is about right. Um but the there will be kids that definitely benefit from extractions. I'm not an extractionist by any sense of the imagination, and I'm not a non-extractionist. I'm just an extractionist in the right situation. And there are certain kids that I get through the doors that I can really ethically say, I will not treat you unless you agree to have teeth taken out. It's not many of them, but they're there, and I will lie in bed very comfortably at night if they walk away and don't have treatment with me. Do you get a lot of pushback from parents? Absolutely. Yeah, absolutely. Um, and I understand it, you know, it is a big decision to extract healthy teeth, but I think this is where good communication comes into it, and it is a relationship that requires trust, just like general dentists with their patients. If that patient doesn't trust you enough to make that decision, then honestly I don't want to treat them because it's going to be an uphill battle the entire time. Whereas if you can have a really good conversation with parents, sometimes over multiple appointments, about why you're thinking about doing it, um, most people will understand if that's the decision that you're going to make.

Dr Jill Fisher 7:28

So I have some questions that Dr. Michael Mandikos has sent across to ask you. So the first one is on retention. So you we see all sorts of styles of retention. There's those little wires that come on that roll that you can buy from Henry Shine, and then you see the the ones that have been custom bent, then the hygienic ones are a little bit more popular now. You see some people that have got lower ones only, uh some with upper and lower, some that have got removable only, and some that have got one of everything. So how do you decide? Um and then you've got those older gen older orthodontists that'll say, you know, it's all garbage. If you get the bite right, it'll all be locked in and you'll be fine. So what is the current understanding on retention and what are we getting our patients to do?

SPEAKER_01 8:16

Yeah, so I think um let's let's talk about the the aspect of if you get the bite right, then everything will be stable. I think it depends on whose definition of stability you're taking on. Um, because from an orthodontic point of view, um, there are plenty of bites that stay really nice and stable with no long-term retention. But those patients might get a little bit of lower incisor imbrication or their upper laterals might rotate, and to that patient, that is unstable treatment. So what we're trying to retain might be different from my point of view and the patient's point of view. The bottom line is most people these days will not accept teeth that are slightly rotated if they've had orthodontic treatment. And that's where this lifelong retention comes into it. Because when you look at maturational, natural maturational change that happens in mouths, in all of us, we all see it. Our lower incisors start to crowd, even if we've had our eights taken out. Um, I always always say to people, it's kind of crazy to think the rest of your face and head can change so much throughout life, but we expect our teeth to stay perfectly straight. And I think that's a that's a nice way of sort of hitting home. And that's true whether you've had orthodontic treatment or not. We change. Um, so it's really interesting because I retreat a lot of adults that had treatment as kids, and often you can tell when they've had really nice ortho to begin with, and I say it to them, gee, your ortho was done really nicely because their occlusion is just beautiful, but they've often got a little bit of lower incise or upper incisor rotation, and that's why they're there.

Dr Jill Fisher 9:50

Yeah.

SPEAKER_01 9:51

There are other cases where absolutely the bite was not or either wasn't or could not be gotten into a position that would uh confer that stability, and therefore we need to put retainers in to help us maintain that sort of stability. Um, so yeah, I think the definition of stability is a really important one to think about. In terms of the design of the retainers, everyone has their favourite thing, and part of it is a patient management point of view uh perspective, some of it is um just logistics in terms of how we go about things. Our routine in terms of fixed retainers, at in our practice, we have come to the conclusion that a custom bent single-stranded wire is the best and a straight wire. And we've come to that conclusion because we found braided wires are plaque retentive and they also can distort and stretch over time. So we find a greater incidence of spaces opening up between um teeth that have been retained with braided wires and more prone to breakage. Hygienic retainers, I could do a whole lecture on the periodonal insult of hygienic retainers. So, hygienic retainers, when I was doing my undergraduate degree, which is 18 years ago or so, were really popular, particularly at the University of Queensland. Um, it's what we were putting on all the orthodontic patients at the time. For good, it had good thought behind it, so that your patients could floss readily. The problem we found with them is that they can distort over time. And we have seen multiple cases of quite severe root torque happening as a result of one of those wires being distorted, which has resulted in very significant gum recession. And so I work with a local periodontist, and almost exclusively my work that I do for him is tucking roots of lower incises back in after it has either had a hygienic retainer or a twist flex wire on there, which has this, it has the same potential to do it. So that's why we haven't um we don't place them anymore. And it's interesting a lot of the periodontists we work with hate them from a hygiene point of view as well, because the little loop actually goes down across the papilla, and so you can't actually floss down both sides of the pillar, the papilla like it was purported to do. So um hygienic retainers are one of those things that we get requests to, and we have lost referrers because we say we will not do them, but we feel that strongly about not doing them.

Dr Jill Fisher 12:22

Interesting. And um, is the only reason not to have an upper retainer then if it won't fit in the bite?

SPEAKER_01 12:30

Um for a lot of people, um, yes. So upper retainers were a lot less common um than lower retainers uh because the breakage rates were considered unacceptable, particularly between the laterals and canines. And often that's because you you haven't been able to open the bite uh enough to be able to fit one in that is still cleansable and and um able to be maintained. Um but the reality is most people will not wear something removable long term. That's just human nature. Um so you still get the patients that come back with their 30-year-old hawley that they're still putting in every night. And that's wonderful, but that's the exception to the rule. Um so if we cannot fit a, if we well, it's usually an adult, if we can't open the bite enough or if there's restorative issues so that we can't place a retainer-why, you know, they've got bridges and that sort of thing anteriorly. Um, we really stress the need for for long-term removable retention if they want those teeth to stay perfectly straight.

Dr Jill Fisher 13:30

So does everyone get an a removable one as well as a fixed one if they've got a fixed one? In our practice, yes. Okay. Um, on the point of the hawley, so this is a question from Michael. As you know, being a specialist prostonist, and you know what Michael's like, everything is really perfect. Um, and one of the issues that uh one of the things he likes to see is a really stable posterior bite. So when you have a hawley, obviously you've got some settling of the bite, but when the patient is set up and they're in these removable retainers, the bite doesn't have the opportunity to settle. So Michael's um been known to at times say, just stop wearing that, let the bite settle, and then we'll we'll make a new one. What are your thoughts?

SPEAKER_01 14:14

So um obviously the ideal situation is that you get a really nice intercuspation before you stop your ortho. That's easily more easily achieved when you've been in fixed appliances compared with clear aligners because there is always a degree of settling that's required post-clear aligner treatment. We find in most people that when we stop wearing clear aligners full-time and transition them to a nighttime regime and possibly an alternating nighttime regime or only wearing one or the other, we find that settles in quite nicely. Most of that will happen within the first three months post-treatment, but it can take up to 12 months to settle in properly. So we I would consider that my active retention phase where I am watching that occlusion settle in. And I will often say, if you can delay any restorative work for that time, that's not a bad idea. But Michael is absolutely right in that a Hawley will allow quicker, more um, more predictable settling if we do that straight away. The problem with a Hawley is it doesn't maintain anterior rotations as well as a vacuum-formed retainer will. So if you're not putting fixed retention because you're wanting to delay that for a restorative phase and then not wearing a vacuum-formed retainer, they'll get movement anteriorly if they're wearing a HOLI, most likely.

Dr Jill Fisher 15:36

So, how long do these vacuum-formed retainers still maintain their integrity for? You know, so you occasionally you see those patients that bring in that crusty old thing that's 10 years old, and you think, is that still working?

SPEAKER_01 15:49

So we say on average about two years, um, but we see plenty of retainers that at two years they still look great and they're still doing their job. So but we we tell our patients that they can expect to replace them that frequently if if we feel like they still need a vacuum form retainer.

Dr Jill Fisher 16:04

And that's an ongoing cost to the patient, or is that part of your service? So that from that two-year mark onwards, that's an ongoing cost. Yeah. And so what what constitutes a retainer that must be replaced? If if they've got that little hole in the occlusal surface because they've been grinding, that is that acceptable? What about the crack?

SPEAKER_01 16:21

From a from a orthodontic perspective, if there's a little hole in it, it's it's fine. Um all wear facets, that's fine. Um it's as soon as it loses its structural integrity from a a stiffness point of view, I suppose that we would look at replacing it. Um so the classic one is like it it's split through the middle, but that's usually because they're being taking it out incorrectly.

Dr Jill Fisher 16:45

Right, okay. Um, the other real thing that I notice in general dental practice, you know, sometimes you've said to me, Oh, you know, I've sent you that case back. I hope you think it's okay. And I think, I mean, it's amazing. But what what would I know? What I'm looking at is is, you know, the occlusion and the aesthetics. But what I'm really looking at is that enamel after the D bond. And I, you know, when my braces were taken off, I was paranoid about my teeth. And your hygienist ash is second to none. And I I'm sure I haven't lost a a scheric of my enamel. She she did such a spectacular job. But I see often these scratched-up teeth that come back really disappointingly. It clearly there's been a diamond burr on those teeth. Um, what is your protocol in the practice? How do you get those patients to have pristine enamel after bonding?

SPEAKER_01 17:38

So um, pretty much all of our D-bands are done by our hygiene staff, and we have got a fantastic team at the moment of specialist orthodontic hygienists. That's all they do. They don't sort of do some days elsewhere, they they work for us full-time. And and they're excellent at what they do. And sometimes I have a parent say, Oh, I want you to take the braces off. And I say, No, you don't. You want them to take the braces off because that's what they do all day, every day. A diamond never touches the labial surface of our teeth at D-Band. So we use tungsten carbide burrs. Um, some and the hygienists will do things differently depending on how they've been trained and what their skill levels are, but um it can be high speed, but we often use a hybrid handpiece as well. Um, and we use uh high uh tungsten carbide burrs followed by um a silicon polishing point, and that's that's how we go about it.

Dr Jill Fisher 18:34

Yeah. Um and what else are these hygienists doing in your practice?

SPEAKER_01 18:39

What's the workflow? Um they are our right hands. They are uh as such an integral part of our team. Um, and so they will do uh they will take modules off, they will replace modules for us. Ash will know what I want to do before I know I want to do it. Um, and she's very rarely wrong about what I want to do. Um so we are incredibly fortunate to work with a team that have stuck with us for many, many years. And so we've got uh a really good working relationship. Um, but I could not run my day without them. They they work alongside me for every single patient. They do not place active, uh they do not make decisions about active appliances, they do not um uh make treatment planning decisions, that is still all us. Um, but uh they they treat every single patient with us.

Dr Jill Fisher 19:31

I mean from a from a personal level, I I'm consider myself very lucky because, you know, our parents are dentists, you're an orthodontist. There's so many times in my working life where I've left the patient in the chair to say, I'm just going to go speak to a specialist, and I go and ring one of you out the back, and you always have the answer for me. Um, and we talk, you know, four or five times a week and often about clinical decisions, and I'm still learning from you in this conversation I've learned a lot from as well. What if you don't have a Liz Fisher on tap? Um, I I saw a comment on the forum recently where someone said, I just I want to make a relationship with the local specialists in my area. I've just moved, I'm a general dentist. I I don't know who they are. I who do I refer to for each of these specialties? But how do we get in touch with you? Obviously, maybe not in the same um way as I'm in touch with you, but how do these general dentists get to know you and our other specialists? And um, what does that relationship look like? Is it always a letter in the post? Is it okay to pick up the phone in the middle of a working day and actually try and reach you? Or can we text you? Can we email you? What do we do?

SPEAKER_01 20:42

Yeah, so I think that's a that's an answer for uh your individual specialists because personally my best, my favorite referrals are the ones that feel comfortable doing that with me. I don't uh I prefer phone calls or text messages because I can get to them and I'm quick at getting back to them. Emails, like most of us that don't sit at a computer all day, um, can sometimes have a little bit of a backlog. But to answer that question on the forum about how do we get to know our local specialists, pick up the phone, you know, just say, hey, I'm Jill. Uh I I'm new to the area. Um, I think most of us specialists, if we see a referral come through from someone that we don't know or someone that we haven't had any interaction with, most of the time we'll try and pick up the phone and introduce ourselves. Um, because it's it's a mutual relationship. So I want to be able to pick up the phone to my restorative dentist and say, hey, what do you think about that? Or I think there was some caries there. Can you just check that out for me next time you see them? Or I'm worried about the oral hygiene. Can you just give them a bit of a rev next time you see them? So it's not a one way relationship at all. Um and I've got that relationship with my other specialist colleagues as well. So if I've got an endo concern, I've got my favourite enodontist on speed dial that I can pick up. So I don't think you'll find many. Specialists that aren't happy to have that sort of relationship with you. Um, I think the trouble is, you know, days get busy and it can be hard to pop out and meet people like you could have done maybe at the start of your career when you were still building a practice. Um, so I think for most people, a phone call is is fantastic and we want that relationship with you as much as you want that relationship with us.

Dr Jill Fisher 22:22

Yeah, great. Um, and I suppose the last question I wanted to ask is potentially a little bit controversial because it's about general dentists doing orthodontics. And I know we can't fight the fact that it is huge, you know, we the you see it everywhere. There's a lot of education for general dentists, there's a big uh disparity in in the um knowledge between a graduate dentist and a specialist, and then I suppose these courses are trying to get us somewhere in the middle. But you've said to me in the past, you know, privately, that some of these general dentists that do also are some of your favorite and best referers. So, you know, we're not demonizing dentists that are that are dabbling in also. Can you just talk about why that is and and and what you think the value in is it is what you think the value is in a general dentist that knows a little bit more than a graduate?

SPEAKER_01 23:17

So exactly. I I think orthodontics is a part of dentistry. You know, we're we're not doing anything out here that's like the dark arts or anything like that. Um, but I do think because there is generally speaking such a lack of orthodontic education in the undergrad um curriculum that uh I think people can get into trouble pretty quickly with orthodontics if they don't have sufficient knowledge and and um and uh training. As I've said to you, some of my favourite and best referers, and I mean best referers as in volume of patients they refer, do their own ortho. And I think those people are so good because they see ortho. They have enough knowledge that when they're seeing the eight, nine, ten, eleven-year-olds in their chair, they're seeing malacclusion. They are seeing dental anomalies that maybe those people that don't do a lot of ortho don't see. And they, if a parent says, when should we get an orthodontic consult? They just say, wait till the adult teeth wait wait till the baby teeth fall out and see what happens. So I um and I think again it comes down to that relationship between general dentist and specialist because I have lots of referrals who I sit down and run through treatment plans with them, I sit down and do clin checks with them. Um, and that's collegiality. Like that's that's achieving the best um outcome for the patient. And I think the biggest thing that I want those general dentists to take away from is case selection, knowing when they're out of their depth. Um, because we all run into that at times. But I think the difference that we have is that we've probably got a few more options in our back pocket of how to get out of that problem. Whereas if you haven't got a lot of experience or seeing high volume of treatment, that can be a troubling situation to find yourself in clinically.

Dr Jill Fisher 25:07

And then if you've got that great relationship with your specialist, you can say, look, Liz, I'm I'm in trouble here.

SPEAKER_01 25:11

100%. And those those people that have got a relationship with you, we will do that in a heartbeat. It's no problem.

Dr Jill Fisher 25:18

Yeah. I mean, we're all going to be humbled. Uh there's a case that comes to mind recently where I I missed uh, you know, an impacted canine on a on a child and I felt so foolish. And I, you know, called my local orthodontist and and he was so kind to me about it all, you know. Um, so I'm grateful to for those relationships because I think that's what helps us all get through the day and service our patients the best we know how. Um, so thanks for coming, Liz. We we really wanted to speak to you because you're obviously my sister. So you're first cab off the rank, but you're so great at explaining these things. You know your topic inside and out. Obviously, Dr. Michael Mandicos has trusted you with his family members and is a referrer as well. So uh it was a no-brainer for us to come and um invite you into chat. And it's been a really valuable conversation for me, and I'm sure it will be for all of our listeners. So, any questions for Dr. Liz Fisher, please send them through. You can send them to info atceodental.com.au. The resources Liz spoke about will be in the show notes, and we'll see you next time. Thanks, Liz. Thank you very much for having me.