Retention as a Starting Point for Interdisciplinary Collaboration

Having spent over half of my career in dentistry as a general dentist (I've been an orthodontist for 12 years, after being a GP for 22), I am particularly interested in those circumstances in which orthodontics and general dentistry overlap.

One of those areas is orthodontic retention. While this may seem to be a trivial matter, orthodontic relapse is a source of resentment and frustration for many patients. I think most of us would agree that having a plan for avoiding resentment and frustration for our patients is something that merits attention.

In addition, I think agreement between GPs and their orthodontists on how retention will be handled is a relatively easy subject to begin with when they are developing a working relationship and determining how they will share their responsibilities for their mutual patients. Patients who have made the investment in time and effort to wear retainers after treatment is complete have demonstrated their commitment to maintaining their post-treatment alignment.

Loss or damage of retainers for such patients, or circumstances that interfere with their ability to use their retainers (lots of restorative procedures fit into this category), can result in orthodontic relapse regardless of how long ago treatment was completed.

However, not all patients with retainers seen by GPs were treated by orthodontists in their referral network; they may have been treated years ago and miles away. These patients, separated by time and geography from the orthodontists who treated them, depend on their GPs for advice regarding retention.

Having a plan for management of retention for these patients, as well as those whose care you share with an orthodontist in your referral network, can be critical for avoiding unnecessary problems related to orthodontic relapse.

In this article, I will offer strategies for GPs who want to help patients avoid pitfalls that commonly disrupt long-term retainer wear, and the subsequent orthodontic relapse that can occur as a result. These strategies will include some that can be useful for patients who were treated by an orthodontist within the GP's referral network, those whose ortho was done by someone with whom the GP does not typically work, and some that apply to both.

​The GP's role in orthodontic retention

General dentists are often asked to clean, adjust, repair or replace retainers. These requests are potentially fraught with hazards, both real and imagined, so many GPs simply avoid involvement with retainers and retention altogether.

For others, it simply has never occurred to them that monitoring orthodontic retention may be a service that would be of value to their patients. In fact, it has been my observation that there is little or no expectation for GPs to have any role in retention.Once patients are finished with orthodontic treatment and whatever retention follow-up is provided by their orthodontist, they are typically on their own. This can leave patients without any means of dealing with problems related to retention.

This is particularly true for post-ortho patients who have moved away from the community in which they lived when they were treated. It is my opinion that retention is within the scope of care that a patient can reasonably expect to be provided by the general dentist. As long as all parties understand and accept the benefits and limitations involved, retention monitored by the general dentist can be the best, and sometimes only, way for patients to manage retention long-term.

So if we accept the premise that having general dentists involved in the management of retention may be of benefit to our patients, why is it not already common? By contrast, consider the GP's role in follow-up with other specialties.

For example, it is typical for the general dentist to share soft-tissue management at some point after periodontal surgery.Endodontists make recommendations regarding post-endo restorations, which general dentists provide. And so on. Given that retention is so crucial to maintaining a beautiful orthodontic result, it would seem that patients, GPs and orthodontists would all have an interest in how long-term retention can be managed and who will do it. As with other specialties, this starts with collaboration and creating expectations.

Creating a plan to transfer responsibility for retention to yourself from orthodontists in your referral network

For orthodontists to whom you preferentially refer, a good way to begin is by having a discussion about their ideas and preferences regarding retention in general, and specifically the transfer of retention responsibility. Since most orthodontists recommend what amounts to lifetime retention, and most also have a defined time after active treatment that they will monitor retention, it makes sense that you should have a plan for transitioning that responsibility from the orthodontist to you. Consider including the following points in your discussion:

• Does the ortho treatment fee include a defined period after active treatment that retention will be monitored? If so, how long? If a patient wishes to have retainers monitored after this defined period, can those arrangements be made? If so, what fees are incurred?
• What type/types of retention does the orthodontist typically employ? If removable retainers are prescribed, what are the usual instructions for wear? Will those instructions be communicated to you, the referring GP, when the patient is finished with treatment?
• What role, if any, does your orthodontist wish you to have when they are finished monitoring retention? For example, how do they feel about you checking/cleaning retainers at routine re-care visits? What about minor adjustments?
• Do they want to have a protocol for addressing relapse for your mutual patients?Do you have an agreement in place for when you see a patient whose retention isn't working? We all know this is a common finding. When we see a patient in our GP practice who has had relapse, we typically assume that they have not complied with instructions regarding their retainer wear, and we also typically assume that they don't want to re-treat the ortho, and leave it at that. An additional assumption is that the orthodontist does not want to see the patient or otherwise know about it. That's a lot of assumptions. I suggest that, while those assumptions are sometimes justified, they do not always accurately portray the patient's situation, and we do our patients a disservice when we do not discuss how relapse can be addressed.
• How do you want to handle retention for patients who require new retainers after restorative treatment or other treatment renders previous retainers ineffective or unusable?

In short, you and your orthodontist should have a plan that will help protect your patients from avoidable relapse due to problems with retention. Of course, you cannot protect a patient who neglects his/her responsibilities for compliance with a prescribed retention strategy, but you also don't want your patients to suffer relapse because no long-term plan has been made.

While this might seem like a lot of fuss for something that most of us have not thought to bother with, consider the following potential benefits to all parties (patients, GPs and orthodontists):

• When the patient hears from both the orthodontist and the GP that retainer wear is important, it reinforces that retention is required to maintain a beautiful result.
• It reinforces the idea that the general dentist and specialist are working together for the benefit of the patient.
• It makes it easier to address the fact that monitoring retention is an actual service and, thus, reasonable fees are justified. (I recognize that the prospect of adding uncompensated services to your case load is not a compelling selling point. Some retention-monitoring services can and should incur charges.)
• It clarifies exactly when management of retention transfers from the orthodontist to the GP, making it less likely that patients will “fall through the cracks.”
• It is a manifestation of the principle (and I think this is a big one) that you, the GP, are sharing your patients with the specialist. If you are going to be directly involved with retention, you have a greater interest in the result that you will eventually be asked to help maintain. It gives support to the concept that you will need to assess the ortho treatment result before appliances are removed.
• It offers patients yet another reason to remain loyal to your practice.
• It makes it easier for you to direct patients to an orthodontist in your referral network when they know that, as part of your collaborative relationship with the orthodontist, you already have a plan in place that considers their long-term interests. (That is not to say that you cannot also monitor retention for an orthodontist outside your preferred referral network; that is addressed later. However, there is nothing wrong with pointing out to patients proactively - that is, when you are making a referral - that you have not established the same sort of working relationship with all specialists as you have with those specialists to whom you refer preferentially).

I hope this has convinced you that it makes sense for you to develop a transfer of retention plan with your orthodontist. Often the easiest way to do this is simply to take over monitoring the retention method provided by the orthodontist. In that case, all that is typically required is cleaning and inspecting the existing retainers. In other circumstances, you may wish to employ some different form of retention. The pros and cons of different forms of retention will be covered in my next article.

Cheryl DeWood D.D.S., Ph.D. is a contributing author to Spear Digest.