Clear Aligner Success in GP Hands: The Case for Orthodontic Collaboration

And if you're kind of flying blind in that treatment, you've just accepted what's come back, how are you going to be able to determine is it compliance? Is it my attachment design? Is it my attachment placement? My attachment angle? Is it the fact that I tried to do a rotation and a root uprighting at the same time as extrusion? Or is it something else with the material? And so I think that that's where a lot of frustration comes in is you don't know if it's any of those things because you didn't plan out those things. And that's no one's fault. It really is that sort of expertise gap that we look to close by collaborating. Welcome to Austin, Texas, and welcome to the Phil Klein Dental Podcast. Clear aligner therapy has become a staple in many general dental practices. But where is the line between opportunity and overreach? In this episode, we sit down with an orthodontic specialist to discuss what general dentists need to know before offering clear aligner therapy in-house. We'll explore appropriate case selection, training requirements, common mistakes, and complications, as well as why collaboration with an orthodontist makes a lot of sense. We'll discuss one particular ortho collaborative service that literally supports and monitors the GP case every step of the way. And that's all done through a specially designed ortho online platform. This episode is a practical conversation about GPs staying in their comfort zone with clear line of therapy with the goal of delivering predictable clinical outcomes. Before we bring in our guest, I do want to say that if you're enjoying these episodes and want to support the show, please follow us on Apple Podcasts or Spotify. You'll be the first to know about our new releases and our entire production team will really appreciate it. Dr. Stout, pleasure to have you on the show. Thanks so much for having me. I really appreciate it. Yeah, it's our pleasure and we're happy to have a board-certified orthodontist on our show, especially to talk about clear aligner therapy, which is the topic of today's episode. And towards the end of the show, we're going to be talking a lot about your innovation in orthodontic collaboration virtually, which is really very interesting. And I think every general dentist who's doing clear line of therapy should know about this kind of interface that can help guide the GP through the cases. To begin this podcast episode, from your perspective, Dr. Stout, as an orthodontist, What are the biggest hurdles you see with clear aligner therapy when it's delivered in the GP practice rather than specialty orthodontic offices? Yeah, so I think it's a great question. It's one we're faced with every single day, both in general practice and the specialty. It's really case selection and how to anticipate. what that looks like from day one. You know, it might be an instance where the patient comes in for a recall or a new patient exam. And, you know, it's not what you're looking at every single day. And you're put on the spot to say, is this patient a candidate? Can I do it? Can I confidently deliver this? And can we get the result that I want clinically as a practitioner and the patient wants aesthetically or for occlusion or function, bite, anything? So I think that there's a lot that happens in that initial decision-making process. The biggest thing with a general practice delivering aligner orthodontics or any orthodontics, whether it's interceptive or fixed appliances versus a specialist, I think comes down to the delta in just sheer experience and volume. And not so much that you can't do it or you shouldn't do it. I believe everybody can and should do it, but it comes down to. case selection comfort and anticipation and you know in my practice we're seeing thousands upon thousands of patients annually um the sheer volume of experience that a typical specialist has means that they're going to have the correct expectations for that case and they're going to translate that to their plan and their communication so that the patient really has a transparent viewpoint on the spot on what is appropriate, what can be achieved. You know, can we correct that midline? Can we correct that class two? And all of those things go into our decision making of saying yes or no for not only treatment, but also the modality. And I think that that's something that is a huge benefit when there's collaborative communication and services is that if an orthodontist is seeing 10 new cases a day and evaluating those and maybe starting seven or eight. The GP might see that in an entire year. And so that volume of just seeing those things, I think, is where we have a communication gap between generalists and specialists. And I think that that's a service we can really provide and close that gap and say. If you're going to do this, here are the things to watch out for. Here are the things to anticipate with the mechanics. Here are the things to modify or trust or not necessarily trust with a product or a movement and really make an informed decision from there on. Is this patient the appropriate case in my office today for what I can deliver? Right. Let me ask you this question. So if an adult patient presents to the GP. for advice on his crooked teeth. Specifically, we're talking about lower anterior crowding, which is typical in adult patients. And after examining the patient, the GP recommends clear aligner therapy. And the patient says, yeah, I've heard about it. I've had friends that have clear aligner therapy. It seems to work very well. But I'm wondering whether I should go to the orthodontist down the road. My kids had their ortho done there. It seems like a good solution for getting my clear aligner therapy there rather than here. How would you recommend a GP respond to that kind of situation? Yeah, I mean, great question. It's definitely a little sticky and it kind of begs at the real underlying thing, which is what is that referral relationship looking like between the practitioners and then ultimately the independent comfort level of that clinician that's being asked that question. And again, I think that there's. Always a benefit for communicating. I think there's always a benefit for, you know, evaluations and opinions and being proactive in that communication. And ultimately, what I think the largest benefit for the patient asking the general practitioner that question is, where is the patient going to feel most comfortable? A lot of cases, simple lower anterior crowding. totally appropriate to be treated in a general office or the specialist office. You know, I know what's typically would be referred to me and it's usually not class one, you know, 20% overbite, mild crowding. That's the easy stuff. That's not coming in through my door. So it's totally appropriate to be treated in the generalist office. The question just becomes, if you take the clinical side out of it, where's the patient going to be best served from a user experience? and a relationship. And then I think it is appropriate to say that we are comfortable treating you here. Yeah. Now, it just seems to me that it is putting a little bit extra pressure on the general dentist when the patient is suggesting to go to a specialist, especially with a high dental IQ, if the patient has that, where they know that a specialist obviously went through a whole lot more training. And as you say, sees tons of cases. Let's get into training for a second. How much formal training and ongoing education do you believe a general dentist should complete before confidently and responsibly offering clear aligner therapy in-house? Yeah, I think there's a wide range that's out there between dental schools. Some of them do some of that, you know, orthodontic training, some of them do none. There's tons of CE, there's tons of free content out there, whether it's webinars, speakers, you know, getting certified with certain brands. And I think the question is any and all is okay. I'm pretty voracious when it comes to self-education and learning and reading. And I feel like most dentists are the same way. We love learning. We love tinkering. We love, you know, expanding what we can do clinically. And so I think as long as there's something, it's better than nothing. And my biggest recommendation for anyone is anytime you start getting into a liner treatment planning, just never accept what comes back to you the first time. You're always going to have a baseline education on, you know, perio occlusion aesthetics. more than anyone else that's looking at this, even if this is your first time getting into a line of orthodontics. So if there's something you see in that treatment plan, ask questions, try to figure out why things are moving, lean on your, whether it's study club or the referral that you normally send things to. I don't think there's any specialist that would get a phone call and say, no, I'm not going to talk to you about a case because ultimately I think we're all collaborative in that. that sense. And I really think that there's the local network effect is bigger than some of the standardized things that can be out there because you're going to learn on a case by case basis. So I think anything's better than nothing. So you mentioned certification, brand certification. What do you think of that from the perspective of an orthodontist? Is that adequate training to get the job done for someone who's new to clear a line of therapy? Or is that just more of a buzzword related to the company that's providing the trays and the design work? Yeah, I think that there's this implied formality of a certification that can come from a brand. And brands want you to go through their process, whether it's monetized or not, so that you can purchase their products. And so I think that it should be taken a little bit with a grain of salt. Does anybody practice for 20 years and say, I've been certified in? placing implants or I've been certified in root canals. Like, you know, it is one of those unique things in aligners. Do I think it's a great starting point? Absolutely. But everyone has to weigh the benefit of the cost of what this means versus the marketing versus what is the actual content. If you're, you know, just clicking through a couple cases, clicking through learning how a product works and really general information, is that money and time better spent than doing webinars or say a study club? in orthodontics or attending lectures in CE. I think that's up to each practitioner. I have my opinion that there's really great targeted orthodontic content out there. And it's not always driven by a tag that says you're certified to use a certain product from a certain company. But that being said, I still kind of lean on something's better than nothing. But the bottom line is the more training you get and the better trainer. the one who's teaching the course, you're going to be better off. So you covered this pretty thoroughly in your Viva Learning webinar. The one you gave, I think, was the middle of January of this year. But perhaps you can briefly address it here. And that is what types of ortho cases are most appropriate for GPs using aligners and which cases should clearly be avoided and ultimately referred to a specialist like yourself? Yeah, I mean, really practical question. I think... The easiest thing to share is, you know, we know that the vast majority of cases that are treated in a GP office are class one, 30 to 40 percent overbite, mild crowding with a slight Bolton discrepancy that requires a little bit of IPR on the lower incisors. You know, it's the number one reason adults come in for treatment. We know that most are adult patients between a certain age range. So I think that that's kind of the, you know, the main. core of the standard distribution that GPs are looking at. And it's also the patients that are coming in and asking for it. Where I think the shift happens for GPs to go from, you know, sort of orthodontics aligners is just something that I do when I'm asked of it to how can I actually build out my services and grow the clinical experience and the business side of it is Everything else besides that. And that's where it comes down to the resources that you have in your back pocket, whether it's the education, the specialist, the virtual platforms. So I would say, you know, bread and butter, class one, mild crowding, mild spacing. You know, you're not really looking at inter-arch mechanics or if there are class two, class three or vertical considerations, you're not trying to bite off more than you can chew, you know, independently. What are the cases on the other side that you probably absolutely shouldn't do? You know, moderate to severe crowding. That's going to be more than six millimeters of arch length discrepancy. Those may require either expansion, extractions or a combination of both. And then any skeletal discrepancies. So, you know, if we're looking at a transverse, a vertical or an anterior posterior skeletal discrepancy, that's really going to be best for by your local specialist because there's. you know, on any one of those cases, there might be three or four different treatment plan options that they want to discuss with the patient that they're going to anticipate pros and cons for that case. So I think, you know, starting off your straightforward class one, you know, where you're doing a little bit of vertical correction, some tidying up, maybe you're getting into some asymmetric IPR for midlines. Then the next phase I'd say is you're getting into moderate considerations for spacing or crowding. Maybe it's a little bit deeper bite or, you know, one to two millimeter open bite. You might start doing some nighttime rubber bands, some inter-arch anchorage, and just starting to broaden out from there your class two, class three open bite, deep bite. And I think that that's really where most GPs can settle in is start off with class one simple stuff, start to expand out to some inter-arch considerations, single tooth cross bites, aesthetic gingival leveling, pre-restorative. Anything above and beyond that, you know, I could get into specifics on, you know, how many degrees and how many millimeters, but I think that's just a good broad range of beyond that, that's really going to be best served by the specialist because there's just so many options. And again, anticipating those considerations. Right. Now these virtual collaborative platforms, they help in the decision for the GP to say, yeah, this case is within my comfort zone and it gets kind of like, you know, quote unquote approved, right? And I think you have one of these, you've developed that you don't have one, you've developed it. And I know you're working with Solventum, which has Clarity. And that's a competitor of Invisalign, I assume, right? The Clarity. Yeah. And I've heard great things about Clarity. Before we get to that, and I want to hear about your collaborative platform, because it fits right into what we're talking about. It keeps the GP in their comfort zone, and it kind of guides them along the way. But let's hit first. the most common mistakes a GP makes, literally in your experience? And I guess you see a lot of cases coming through Bsmile, which is the portal we're going to be talking about. What are we looking at as far as the most common mistakes a GP makes? They're excited about clear aligner therapy. They took some courses. They may be certified. And whether it's in diagnosis, treatment planning, or case monitoring, where are they going wrong for the most part? Yeah, absolutely. The number one mistake. I see is that they're over trusting the product and accepting what comes back to them sort of from that first evaluation from the company. And that's across the board. It doesn't matter what aligner system they're using. We transition obviously a lot of practices into our collaborative system. And what we hear most often is. Kind of like I didn't know what I didn't know before coming into the collaborative side of virtual, you know, dentistry. And I think that that's the number one thing I can say is whatever you get back, that first clincheck, that first treatment design, that first setup, don't accept it. You know, go in, edit it, look at those. Why is that? Why shouldn't. accepted is the technology the digital transfer of acquisition of the data that's coming from the patient via the dental office to the company that's making these trays? Is that not enough to put them on the right track right off the bat? Yeah, so the data input to the company is exceptional. You know, we've got awesome scanners, 3D images, all of that. It's just what you're getting back is, you know, a combination of an algorithm, potentially now some AI, and then it's a trained technician. And I think that what we hear a lot of times is that the expectation is that there's... someone with higher level training clinically on the back end. And they're usually surprised that there isn't. And so that's why I said a little earlier, you know, kind of no matter what, you're going to be more of a doctor, even if you're not an orthodontic specialist, you're going to know more than probably. the individual or the system that set that up. So at the very least, you owe it to yourself to go through the exercise of editing that, seeing it, you know, and starting to look for some of these little tips and tricks. And it's stuff that we learned in our residency, which is, you know, you know, that a common mistake or common thing that gets. people frustrated is like posterior open bites or, you know, number seven and 10 don't extrude. It doesn't track or a tooth doesn't rotate past 15 degrees. And so there's certain things that we kind of know as specialists on how to overcorrect that and how to overcompensate it. And those things are not going to be built in by a company in that first design back. So when that first design comes back, if the GP goes with it. they'll see that it's not tracking accordingly. And they're going to see the results as they bring the patient in. Even if it's a quick peek, they'll look at the little movie on the screen that the company provided. And then they'll look in the mouth and they'll say, hey, this ain't matching up. Then they make that correction, right? And I think that that's where some of the frustration we hear is two things. You know, you get smile designs or smile simulations, and that's exactly what they are. They're simulation. They don't take into account the physiology of remodeling and the soft tissue and smile arc and occlusion and wear patterns and all those things we know as dentists. But they're also not taking into account how to stage the movements and the mechanics. The biggest thing we hear frustration wise is lack of tracking and sort of an overuse of IPR and refinements. And the GPs are sort of swirling. They're saying, I've done IPR. Why didn't the overjet correct? Or I can't get this thing to track and I'm on my fourth refinement. And oftentimes we work with them to unpack. It goes all the way back to the initial screening, the diagnosis and the treatment plan. and accounting for those things. How much of the not tracking is attributable toward poor compliance by the patient? And how do you determine that, you know, other than the patient saying, yeah, I'm only wearing the trays 15 hours, I know I need to wear them 22. And some will say they're wearing them 22 when they're wearing them 12. So how does that come into play so that you know what to go after? Yeah, so I think that there's... a fundamental outlook from our perspective which is the patient needs to be accountable for compliance and if you educate them on the expectations and they're compliant then things should track And things should track based on the materials and the attachment design, as well as the staging mechanics of the movement. So I think that there's a couple of factors there. And it's our job as clinicians to understand the variables that we have removed. And if you're kind of flying blind in that treatment, you've just accepted what's come back. How are you going to be able to determine, is it compliance? Is it my attachment design? Is it my attachment placement, my attachment angle? Is it the fact that I tried to do a rotation and a root uprighting at the same time as extrusion? Or is it something else with the material? And so I think that that's where a lot of frustration comes in is you kind of, you don't know if it's any of those things because you didn't plan out those things. And that's no one's fault. It really is that sort of expertise gap that we look to close by collaborating. Compliance can be a huge factor. Right. And I do want to get into your collaborative platform, but I do want to ask you about posterior open bike because you did mention it. And that is a common recurring issue with aligners. therapy what typically causes posterior open bite and should it and how should it be prevented or corrected when it occurs yeah so obviously it's the most common thing we see throughout treatment and um without getting too in the weeds of the biomechanics you know if you consider that aligners have an occlusal coverage you know component that braces do not and so that occlusal coverage with the occlusal forces is going to put an intrusive force on the posterior teeth and that intrusive force is going to have a few different vectors that are going to potentially you know intrude the whole tooth intrude just the buccal cusp create sort of a curve of wilson in the posterior and all those things show up clinically over time as an inadvertent side effect of the occlusal coverage of the aligners you'll see it with night cards you know depending on how they're designed or a lot of other things. And so one of the simplest things you can do is if you get that first treatment design clincheck back is add a tiny bit of extrusion to all of the posterior teeth in appropriate cases. You wouldn't necessarily want to do that in an open bite case, but let's just say it's kind of a normal case, 20% overbite. By putting in say a quarter of a millimeter of extrusion on the posterior teeth, you're creating a counteracting force to that inadvertent force that happens just by nature of the appliance and so it's simple things like that where you can start to if you understand the mechanics you start to not put the mechanics in that you want it's more so putting in mechanics to prevent what you don't want to happen yeah that's all orthodontics is it's it's anchorage and it's the equal and opposite forces that are working against the thing you want right um The only time we have absolute anchorage is when we have bone anchorage with, you know, temporary anchorage devices. And, you know, you're not going to be doing that. So that's where it comes into play where it's like that tooth can't just move one direction. Yeah. Let me ask you one other question about posterior open bite before we go on. What do you think about trimming the trays back by cuspid to by cuspid? For instance, in a case where you're trying to. correct, um, anterior crowding, and then you cut it back, you would leave that occlusal plane in the molar area and allow those molars to erupt back into their, uh, proper position. Potentially. So, um, that's definitely a tactic we use to allow for natural settling. Uh, you could also disarticulate the anterior through bite ramps and we could probably do a whole 30 minutes on. where to put bite ramps and why. You can also overcompensate the extrusive force in the aligners, or it could be a combination of all three of those things. But yeah, absolutely. You know, sectioning off posterior teeth is something we recommend all the time. And especially, you know, retention is an active, not a passive process. And so that's also another trick, you know. with braces versus aligners is you might have kind of point contacts in the posterior when you finish an aligner case. And that's perfectly normal. Just allow the settling, allow the teeth to come together and section off the aligners, monitor it for say, you know, eight to 12 weeks. And those bites will sort of physiologically close. The question is becomes how big is your posterior open bite? When did you catch it? When did the patient come in? How tightly are you monitoring it? And then from there, which of those sort of three or four tactics do you need to use in combination? so i do want to talk about in this episode your collaborative platform bsmile i think the whole concept is extremely interesting and with the way digital dentistry is going today for a dentist who's especially new with clear line of therapy to have access and the opportunity to show their case from the beginning all the way through the end to orthodontists and having the same orthodontist work with that dentist along the way seems like a huge advantage. So give us a brief overview of what that's about. Yeah. So first and foremost, we are a collaborative and educational resource. The whole philosophy behind it is we're better if we all work together, right? There's barriers to care for expertise, geography, materials, all of that. We work with existing cases, you know, docs that are joining our platform and saying, hey, we need help on this. And then ultimately we work with them proactively to plan out cases for the full vertical. So it's the materials, operational training, education to make them a subject matter expert on each case. We want you to understand. Anchorage, attachment design, vectors, biomechanics. We want you to know the ortho, which is really unique and kind of the polar opposite of what's out there. So in addition to a lot of the resources that you provide on your portal, you look at the case individually and actually determine whether that case is something that the general dentist should pursue or not. Yep. So our portal that's free to join, there's free resources on there where they can learn about, you know. biomechanics and staging. But then every single case that gets uploaded, we screen it to make sure it's an appropriate case for that practice and for that doctor, because it's really a bespoke service. We know the patient demographics, the vision of the doctor. We might have some practices doing more complex things than other ones. And then once that case is worked up by their assigned board certified orthodontist, they're going to get a lot of content to review for that case. So they're going to get the diagnosis, the etiology, We provide the support for the team and the patient, informed consent treatment plans. They get their 3D viewer that they can manipulate and see the before and after. And then they're also going to get a custom educational video for that case. And it's going to explain everything they need to know or anticipated answers to questions from patients about that case. And then ultimately they get to decide if they want to do that case and present it to the patient. We are completely free for all of that service. because it is our contribution to the industry. And it's ultimately an access to care consideration, in our opinion. We want patients to have the best possible treatment, no matter where they're getting it from. So I like to say, instead of referring out, you're referring in expertise. And everybody wins, because we're putting that quality first. So once a dentist decides to participate in the program, there's a fee for that. What is covered? with that fee? What's the full package look like? Yeah. So our vertical includes everything. So it's the software, the educational component, training, operational evaluations, and consulting. And then it's the aligners, unlimited refinements, retainers, and basically a 24-7 on-call assigned board certified orthodontist to help with everything from starting the case, delivering the case. refinements, retention, retention monitoring, and then further case selection for that practice. So it's really, you know, I would say it's not so much that you're just like buying aligners. It's not so much that you're just asking an opinion. You are getting this sort of full service virtual ortho practice with the full team in your pocket. So there's a real orthodontist on every case, not just AI. Absolutely. 100% US-based ABO board certified orthodontist. It's actually assigned to the practice. So it's not even like if you upload 10 cases, you're going to get 10 different orthodontists working it up. You are going to get just me and I'm going to take care of everything you need to know. I'm going to know your team. I'm going to know you. I'm going to know where you're at, your practice demographics, what your vision is, and we're going to make informed decisions together in a collaborative manner. I mean, this sounds like it's going to be very successful. I know you're an entrepreneur. On your webinar, you recommended some really good books about innovators, including Steve Jobs and General Magic. You had a book on, which was the iPhone of 30 years ago that never came to market. Yeah, really interesting stuff. And it's really exciting to speak to a... a dentist, orthodontist, and entrepreneur, but you're working with a great company too, formerly 3M, right? Solventum is a worldwide company. So for you to align with them, no pun intended, it's a fantastic relationship. So how do you plan to build that out if it becomes swimmingly successful, which it probably will? You have to get more orthodontists on board, right? Yeah, so I appreciate that question. There's a couple different layers to it. So I started the company January 2021. We now service, you know, couple hundred practices, including groups and DSOs and mid-market players across all of North America, including all of the provinces in Canada. We have a couple of different things that obviously we've scaled. One is we have a wonderful relationship with Solventum. And that really came from my own clinical preferences for their materials. They have really unique capabilities in their software and their plastic and their materials and their attachments that we leverage to help optimize the mechanics. the operations. We don't gatekeep any information. We want everyone to basically function the way I would function in private practice as an orthodontist. The second thing is we're leveraging certain resources on our end, and that means systems. It means standardizations on our protocols. It's predictability. It's being able to give the correct expectations that we know we can deliver at scale with our GP. you know, pediatric periodontic partners that join this platform. But we do that through scaling our expertise. And so we do have multiple orthodontists who work within the company and get assigned to these practices. And I can tell you, you know, we can do some impossible things that were never available. So, you know, there is a point where the practitioner's capacity gets tapped out, even in something like orthodontics, where, you know, we might be sometimes a little less hands off in certain clinical aspects. I can tell you, you know, I'm proud to say I handle over 150 clients just myself. So it's a really great scalable platform for the specialist because. The orthodontists at work with us, this can be something that they do on vacation or parental leave, or it can be something that, you know, they do on an off day or between their own patients. And it really gives a lot of flexibility for them to scale their expertise. And it also gives them the opportunity to decouple their career from, you know. from a clinic chair right and you work with any retired retired orthodontists yeah yep so you know i'm proud to say like some of my own faculty from my own residency work with us um and you know there's a certain criteria you know we want a certain level of experience board certification they have to you know have their own practices and understand management and operations and all of that um and it's it's really great because i think everybody wins in this model You know, GPs are able to do more. We're able to do more and the patients get more. So as we wrap up this podcast, tell us what the first step is for your company, your collaborative platform to engage with a dental practice that's looking to get started. For us, we do an intro call, make sure it's the right fit, make sure we're aligned on the right goals and that, you know, we're going to be successful on both sides of this. And then it's really starting the bespoke service on a case-by-case basis. And it's just, If you can take pictures and you can take a scan with any scanner, you can upload it and we're going to start to educate you on this. And your website, besmile.com, obviously allows dentists to poke around for free and learn all about it. Yep. We have, you know, registration is an email. You can just... roll right into it through our registration link. Info at besmile.com is a great place. From the website, you can start, you know, asking questions. We'll answer it. We'll guide you on the right pathway. You know, there's a self-scheduling app that, you know, anybody that's interested can book a 15, 30-minute call with me and we can talk through, you know, is this the right fit? Where are you at in your journey? And what resources do you need? And besmile, by the way, is B-E-S-M-I-E. S-M, as in man, Y-L-E. Yep. Great stuff, Dr. Stout. We're really very happy that you came on the show. I mean, this makes sense. There's a lot of dentists out there that are doing clear aligner therapy. Hopefully, they're getting good success with it. There are a lot of dentists that are on the fence. They don't feel comfortable enough to start. This is certainly an option for them, giving them more confidence with their cases, reducing the stress of the cases, planning better, getting better results. And of course, when the teeth are aligned, conservative restorative dentistry usually follows. That helps the patient, that helps the practice, and everybody wins. Dr. Stout, thanks so much for your time, and we appreciate you being on the show. Thank you. I appreciate it.