There has been a sizable shift in the way that Orthodontists begin their specialist careers in practice. It is not uncommon for new specialists to travel far and wide to work for a number of different practices.
In this environment, starting an orthodontic service in an ongoing general practice is appealing. You may have several dentists with their own list who provide a ready-made referral base, a hygienist who can aid in maintaining oral hygiene, and communication between yourself and the referring GDP is made simpler through shared premises. I have found it can also be a stimulating experience for your staff who may have never experienced working in anything other than a general practice environment.
Starting an Orthodontic service in practice when you have spent the last 5 years in the hospital service, however, isn’t straightforward. Very suddenly you need to start thinking about material costs, bracket systems and advertising – all of which you likely took for granted in your training days. I decided to write this blog, therefore, as an account of some of my experiences of starting an Orthodontic service in my third year of specialist training. It is very much aimed at those who are moving from a hospital based service to starting their practice for the first time.
- What treatments Tads/lingual etc
- Links with consultants/other practices for more difficult cases/help planning
- Trade fair
- Existing links
- Own equipment? Eg camera
- Types of treatment
- Set ups
- Getting dentists on board
- Free consultations
- Presentation to other GDP’s
1. Define your scope of practice
Modern day options for patients wishing to have orthodontic treatment are numerous – ranging from metal or ceramic brackets, self ligating, lingual appliances, aligners and TADS. The ability to offer your patients a myriad of options is enticing, particularly when you have spent years of training to provide high quality treatment.
However, it is likely that it will take some time to build up a list of patients and at an early stage stocking a variety of appliances will mean more stock, and a larger start up cost. One of the first things that we did when I started at Queensway Dental Care was to define, very explicitly, the types of treatment we would be providing, and keeping these to a minimum at the start. We decided to stock only ceramic labial fixed appliances, with a small stock of metal lower incisor brackets for deep bite cases. This meant we could buy this bracket in greater bulk (and therefore at less cost per bracket) than if we had also stocked a metal or self ligating appliance.
Furthermore, consider the complexity of cases you wish to take on. Treating adults with orthodontics vastly different to treating adolescents, and early on it can be very helpful having links to more experienced colleagues in the local area for onward referrals or help treatment planning. From this point of view establishing the practice while I was still training was advantageous as I was able to quickly get second opinions on more complex cases – and in one instance where I was not able to provide treatment (in this case a complex malocclusion needing significant restorative input) these links meant I was able to provide an onward referral quickly and efficiently. Although this did mean I didn’t provide the treatment in this case I feel it reflected better on the practice than ending the conversation without helping the patient at all.
If you are starting an orthodontic service de novo it is important to bare in mind that the startup costs can be high, with new fixed kits, retractors for photos and bond up, brackets, wires, auxiliaries and a DSLR if you don’t have one likely to be on your shopping list.
With this is mind it is worth waiting until the annual British Orthodontic Conference prior to committing to any purchases. Not only can you meet representatives from all the major manufacturers in a relatively short period of time but you will get to see the equipment in person and establish the quality of what you want to buy. Having tried the equipment from most of the major manufacturers, I left with a sizeable order of Ixion equipment knowing I had bought a quality product. The DB team were very welcoming and more than happy to guide me through the process of purchasing the equipment for the first time.
It helped having a comprehensive checklist of what I wanted to buy, and I have included this at the end of the post. It's worth bearing in mind that although you may want to buy most of the equipment from specialist orthodontic vendors, it's also worth looking at the vendors your practice has established links with already for the sundries.
3. Staff training
A well trained, highly motivated team is one of the biggest assets you will have in starting your practice. We were very lucky to have a nurse and practice manager who were very enthusiastic about setting up and promoting our new service to existing patients of the practice, and I was well booked when I started.
For me, it was important that they felt at ease with providing orthodontics as quickly as possible. As I was only working one Saturday a month it meant that the exposure they got to orthodontics made up a small part of their working lives, and any information they picked up one month was likely going to be drowned out by their many other duties at the practice.
To help them with this I spent an afternoon making up a small handbook for them to refer to when they were stuck. Information on both treatments we provide (and don’t provide), patient flow from initial consultation to debond price list, equipment check lists for each procedure and ordering codes for new equipment were all added to this book. This gave my nurse a quick reference guide to help the running of the practice while I was away, and facilitated workflow for what was inevitably a small part of my nurse and practice managers working week.
My nurse had this to say about starting the service:
“My first experience as an Assistant in orthodontics was very interesting and something completely different to other treatments that we do daily in dentistry. I had read books and even seen videos to gain more knowledge on treatments in this field. When we started booking patients for consultations I thought it was going to be difficult as this is a new treatment and something new to promote. It’s rewarding to see how people can become more confident with a simple change in their smile.”
Learning a new discipline was clearly very stimulating her, particularly when she had previously only worked in general practice, and this added benefit for your staff shouldn’t be underestimated!
4. Practice Promotion
As you will be aware, promoting your service is critical to getting patients in. There are a couple of simple promotions that you can utilize to try and start getting you list filled:
1) Get established clinicians in the practice on board early. Excellent working relationships with GDPs or other specialists working in your practice is critical. A general dental practitioner that has been working in a practice for several years will know their own patients well, and are an excellent source of high quality referrals.
The orthodontics that you provide can play an important part in the multi-disciplinary management of adult patients, particularly with alleviation of crowding and creating space for an osseo-integrated implant, and if you can demonstrate how your orthodontic treatment can improve their treatment outcomes your colleagues will be more motivated to make the referral. An easy way to do this would be to set up a lunch and learn, or similar CPD event, showing clinical cases that you have treated with a significant restorative input.
2) Advertise early. As soon as you have an agreement with the practice you will be working at, look to get the advertising done as soon as possible, even if you clinics have not yet been set up. At our practice, notices were placed in the patient waiting room for free orthodontic consultations around 4 months before I started working. By the time I started, I had a full list of consultations for my first day. Having this offer up on the practice website is also a huge help.
A brief word of warning about free consultations – they are fantastic for getting people through the door but many patients will not be serious about taking up treatment. We had one gentleman who thanked me very much for the estimate and advice but he would get the treatment done elsewhere as his GDP had promised to offer treatment for less than the rest of the competition had offered!
3) Get a price list made before you start your consultations and have this agreed with the practice. This can be a little bewildering to start but communicate with the practice management and use them as a guide.
Overall, starting up your own service for the first time can be a totally different challenge to what you may have experienced before in your career, but can be incredibly rewarding once it has started.
Use the people around you to guide you, whether that is more experienced Orthodontists you may already by working with, the staff at your new practice or the excellent help from DB, and be patient! It took 4 months of working 1 morning a month before I had my first bond up – and it will take even longer before you have an established list. Most of all, enjoy the journey and you will have the satisfaction of your own list before you know it.
4. Equipment Checklist
Fixed Kit (x3):
- Light wire
- x2 Mosquitos per kit
- Distal end cutters
- Ligature cutter
- Crimpable hook pliers (1 in total)
- Saliva ejector
- Cheek retractor
- Plastic dry guards
- Bracket tweezers
- Photo retractor
- Photo mirror
- Band seater
- Band remover
- Quick lig
- Long lig
- Dead coil
- Push coil
- Power chain
- Crimpable hooks and stops
- Inter-max elastics