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Integrated Clinical
Orthodontics

Edited by

Vinod Krishnan, BDS, MDS, MOrth, RCS Ed

Professor, Department of Orthodontics, Sri Sankara Dental College, Trivandrum, Kerala, India

Ze’ev Davidovitch, DMD, Cert Ortho

Professor of Orthodontics, Emeritus, Harvard University, Boston, Massachusetts, USA
Clinical Professor, Department of Orthodontics, Case Western Reserve University, Cleveland, Ohio, USA

A John Wiley & Sons, Ltd., Publication

This edition first published 2012
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Library of Congress Cataloging-in-Publication Data
Integrated clinical orthodontics / edited by Vinod Krishnan, Ze’ev Davidovitch.
    p. ; cm.
  Includes bibliographical references and index.
   ISBN 978-1-4443-3597-2 (hardback)
  I.  Krishnan, Vinod.  II.  Davidovitch, Zeev.
  [DNLM:  1.  Orthodontics–methods.  WU 400]
  LC classification not assigned
  617.6'43–dc23
2011034246

A catalogue record for this book is available from the British Library.

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Set in 10/12 pt Minion by Toppan Best-set Premedia Limited, Hong Kong

1  2012

Dedicated to

My ever-inspiring family, who supported me throughout this project
My children, Jithu and Malu

My mentors, Dr Jyothindra Kumar (orthodontist) and the late Dr Ponnuswamy (anatomist),
who changed the way I looked at my profession

and

All those who would love to see advancement in the ‘Science of Orthodontics’

Vinod Krishnan

My wife, for her continuous support and advice; my children, for their compassion and constructive suggestions;
and my grandchildren, for their excellence in computer science

Ze’ev Davidovitch

Dedication

Laure Lebret and Anna-Marie Grøn: for lives team, both had solid and independent cores with sharp
committed to integrated orthodontic education minds and caring dispositions. They were involved with Dr
Moorrees in seminal studies on the dentition and various
It is fitting to dedicate a book titled Integrated Clinical aspects of facial growth, the most important of which was
Orthodontics to two teachers whose lives were committed a long-term study of over 400 sets of twins, investigating
to interactive and integrated education: Laure Lebret and the relation of facial and dental development.
Anna-Marie Grøn. Both were full-time faculty members in
the Departments of Orthodontics at the Forsyth Dental In addition to co-authoring papers with Dr Moorrees
Center (initially The Forsyth Infirmary for Children and and other workers on dental development, natural head
now The Forsyth Institute) and the Harvard School of position, and the mesh diagram analysis, Laure Lebret
Dental Medicine. The two affiliated institutions co-spon- worked and published on the growth of the human palate,
sored the orthodontic postgraduate program in an unparal- the reproducibility of rating stages of tooth movement, and
leled combination until 1990. Together with Dr Coenrad F physiological tooth migration. While tackling with Dr
A Moorrees, the Chairman of both departments for over 40 Moorrees the principles of diagnosis and also dental devel-
years, they were the pillars of a unique educational program. opment, Anna-Marie Grøn’s role was cut in the equally
The fact that the three of them originated from three dif- demanding and meticulous research of reproducibility of
ferent countries stands as an important detail in the history rating stages of osseous development, and the prediction of
of a program whose graduates have spread worldwide, car- the timing of tooth emergence. The research that both
rying with them the notion that professional excellence women engaged in was not easy, for they mastered the
requires constant curiosity, and a search for contributing intricacies of, and fully understood the variations in, clini-
factors derived from any reasonable source. Coenrad cal research, let alone longitudinal investigations with thou-
Moorrees was born in Holland, Laure Lebret in France, and sands of collected measurements per child. Their inquiry
Anna-Marie Grøn in Denmark. Each was touched with was clean, responsible, and painfully detailed. Their publi-
difficult experiences during the Second World War. cations are, currently some 40 and 50 years later, having an
impact on clinical decisions for thousands of children
To many generations of Harvard/Forsyth orthodontic worldwide. One particular summary of much of the com-
graduates, our education was nurtured with the indelible bined efforts of Lebret, Grøn, and Moorrees is embedded
impact of these three teachers, who were role models of in a paper entitled ‘Growth studies of the dentition: a
civility, collegiality, scientific thinking, and productivity. Dr review’ (Moorrees CF, Grøn AM, Lebret LM, Yen PK,
Moorrees departed in 2003, Dr Lebret in 2009, and one year Fröhlich FJ, American Journal of Orthodontics 1969; 55:
later, Dr Grøn joined them, leaving behind a legacy of 600–16). Rarely is it not referenced in a paper or chapter
goodness, along with the hard and patient work of educat- on dental development.
ing hundreds of orthodontists, many of whom became
academicians, among them an unconventional number of Beyond the research and organized, clear didactics, the
chairpersons or program directors. clinical teaching of Grøn and Lebret was in line with what
today is labeled evidence-based practice and critical
Laure Lebret and Anna-Marie Grøn were pioneer women, appraisal. ‘Justify the plan’, was their modus operandi, and
as dentists, orthodontists, and postgraduate teachers. ‘consider the alternatives’, before you decide. They were not
Known as the important cornerstones in Coenrad Moorrees’ necessarily unique in these requests. They simply trans-
ferred their research experience into daily clinical practice.
They translated the central tendencies developed by research
into the individual environment, to choose and deliver
sound individualized treatment. That was the educational
culture they helped us go through, and later propagate on
our own as we became educators.

For all the gifts of knowledge and humanity they bestowed
on their students worldwide, we dedicate this book to Laure
Lebret and Anna-Marie Grøn. They deserve recognition in
a book built around the idea of integrated sciences in the
ever-expanding world of clinical orthodontics. By honour-
ing their memory, we acknowledge that the explorations are
going on, extending from theirs, for the benefit of mankind.

Joseph G Ghafari, DMD
Ze’ev Davidovitch, DMD

Contents

List of Contributors xiii
Preface xvii

Chapter 1 The Increased Stature of Orthodontics 1
Chapter 2
Chapter 3 Ze’ev Davidovitch, Vinod Krishnan 1
Introduction 4
Chapter 4 The broadening scope of orthodontics 4
The orthodontic patient as a human being 5
The patient’s biological status – does it influence orthodontic treatment? 9
Conclusions 14
References
15
Effective Data Management and Communication for the Contemporary
Orthodontist 15
16
Ameet V Revankar 17
Introduction 22
The role of information technology in the orthodontic practice 28
Computer-aided diagnosis and treatment planning to enhance communication 32
Other arenas of communication 34
Electronic data management 35
Virtual patient record for integration of specialties
Conclusion 37
References
37
Orthodontic Diagnosis and Treatment Planning: Collaborating with 38
Medical and Other Dental Specialists 38
38
Om P Kharbanda, Neeraj Wadhawan
Introduction 39
The other side of the story 50
Orthodontic diagnosis from a broad perspective 60
The first interaction with the patient 62
The importance of the medical history in the orthodontic diagnosis and 62
treatment planning 65
Identifying local dental abnormalities before attempting orthodontic treatment
Evaluation of the occlusion and the temporomandibular joint 69
Radiographic examination of the jaws
Conclusions 69
References 69
77
Psychosocial Factors in Motivation, Treatment, Compliance, and
Satisfaction with Orthodontic Care

Donald B Giddon, Nina K Anderson
Introduction
Motivation for orthodontic care
Psychosocial variables influencing compliance

viii  Contents Conclusion 80
References 80
Chapter 5
Chapter 6 Nutrition in Orthodontic Practice 83
Chapter 7
Lauren Schindler, Carole A Palmer 83
Chapter 8 Introduction: the role of the orthodontist in nutrition 84
What is an adequate diet? 86
Nutrition and the orthodontic patient 89
Effective nutrition management of the orthodontic patient 94
Conclusions 94
References
96
Anomalies in Growth and Development: The Importance of Consultation
with a Pediatrician 96
97
Adriana Da Silveira 98
Introduction 100
Pervasive sucking habits and tongue thrusting 106
Growth-related problems 107
Trauma-related issues
Conclusions 109
References
109
The Benefits of Obtaining the Opinion of a Clinical Geneticist Regarding 109
Orthodontic Patients 110
111
James K Hartsfield Jr 112
Introduction 115
Interaction with the clinical geneticist 116
Evolution of the clinical (medical) geneticist specialist 118
When to refer? 120
Radiographic signs 120
History of premature tooth exfoliation 121
Conditions in which premature tooth exfoliation may occur occasionally 122
Supernumerary teeth and hypodontia (oligodontia) 123
Syndromic hypodontia 124
Supernumerary teeth or hypodontia (oligodontia) and cancer 124
Failure of dental eruption 125
Soft and hard tissue asymmetry 127
Maxillary hypoplasia 128
Functional (neuromuscular) asymmetry 128
Mandibular retrognathism
Connective tissue dysplasia 132
Cleft lip and cleft palate
Conclusion 132
References 133
143
Multidisciplinary Team Management of Congenital Orofacial 148
Deformities 149
150
Sherry Peter, Maria J Kuriakose 150
Introduction
Otofacial malformations
Craniosynostoses
Achondroplasia/FGFR3 mutations
Holoprosencephalic disorders
Conclusion
References

Contents  ix 

Chapter 9 Cleft Lip and Palate: Role of the Orthodontist in the Interdisciplinary 153
Chapter 10 Management Team
Chapter 11 153
Anne Marie Kuijpers-Jagtman 154
Chapter 12 Introduction 154
Chapter 13 Interdisciplinary team care 156
Members of the cleft lip and palate team and their task 165
Orthodontic management 165
Conclusions
References 168

What can Orthodontists Learn from Orthopaedists Engaged in Basic 168
Research? 175
177
Carlalberta Verna, Birte Melsen 179
A common language 180
Bone adaptation to mechanical deformation and orthodontic tooth movement
Bone reaction to skeletal anchorage 182
Conclusions
References 182
182
When Should an Orthodontist Seek the Advice of an Endocrinologist? 184
184
Nadine G Haddad, Linda A DiMeglio 185
Introduction 186
Growth hormone deficiency 187
Growth hormone excess 188
Thyroid disease 190
Hyperparathyroidism-jaw tumor syndrome 191
Hypophosphatasia 192
Rachitic disorders 192
Osteopetrosis 193
Fibrous dysplasia 193
Diabetes
Adrenal disorders 195
Turner syndrome
Conclusions 195
References 195
197
The Benefits of Consulting with an Ear, Nose, and Throat (ENT) Specialist 211
Before and During Orthodontic Treatment 211
211
Joseph G Ghafari, Anthony T Macari
Introduction 214
The anatomical connection: the mouth in its relation with the nose, throat, and ear
Areas of interaction 214
Conclusion 215
Acknowledgments 215
References 217
218
Obstructive Sleep Apnea: Orthodontic Strategies to Establish and Maintain 221
a Patent Airway

Mimi Yow, Eric Lye Kok Weng
Introduction
The spectrum of obstructive sleep-disordered breathing
Decoding OSA
Respiration: effect of anatomy and sleep
OSA in children
OSA in adults

x  Contents Conclusions 230
Acknowledgments 234
Chapter 14 References 236
Chapter 15
Acute and Chronic Infections Affecting the Oral Cavity: Orthodontic 240
Chapter 16 Implications
Chapter 17 240
Vinod Krishnan, Gunnar Dahlén, Ze’ev Davidovitch 241
Introduction 248
Bacterial infections 250
Chronic infections with oral manifestations 256
Viral infections 260
Fungal infections 261
Parasitic infections 262
The oral cavity as a source for focal infections 263
Conclusions
References

Orthodontics and Pediatric Dentistry: Two Specialties, One Goal 267

Elliott M Moskowitz, George J Cisneros, Mark S Hochberg 267
Introduction
Coordinating orthodontic and pediatric dental appointments in a group or solo practitioner 268
setting 270
Identifying orthodontic and pediatric dental problems earlier than later
Restoring form and function – revisiting the unilateral posterior crossbite with a functional 272
mandibular shift 275
Congenitally missing maxillary lateral incisors – who does what, when, and how? 279
Retention considerations and beyond
Enamel demineralization during orthodontic treatment – who takes responsibility for 280
prevention? 282
Conclusions 282
References

Dental Caries, Tooth Fracture and Exposed Dental Pulp: The Role of 283
Endodontics in Orthodontic Treatment Planning and Mechanotherapy
283
Neslihan Arhun, Ayca Arman-Ozcirpici, Mete Ungor, Omur Polat Ozsoy 284
Introduction 286
Pretreatment evaluation and early orthodontic treatment 292
Interactive collaboration during orthodontic treatment
Emergency orthodontic treatment in trauma cases 305
Immediate post-orthodontic period, and the long-term retention requirements for 307
avoiding relapse 307
Conclusion
References

Pre-Prosthetic Orthodontic Tooth Movement: Interdisciplinary Concepts 313
for Optimizing Prosthodontic Care
313
Julie Holloway, Meade C Van Putten Jr, Sarandeep Huja 314
Introduction
Case 1: Orthodontic intrusion 314
Case 2: Use of dental implants for anchorage and orthodontic tooth extrusion for implant 320
site development 322
Case 3: Minor tooth movement to gain canine guidance for full mouth rehabilitation 324
Orthodontic techniques in maxillofacial prosthodontics 327
Case 4: Restoration after a maxillectomy for osteomyelitis
Case 5: Prosthetic restoration of maxillectomy due to adenoid cystic carcinoma

Contents  xi 

Chapter 18 Conclusions 330
Chapter 19 Acknowledgments 330
Chapter 20 References 330
Chapter 21
Chapter 22 Orthodontic Treatment in Patients Requiring Orthognathic Surgical 332
Procedures
332
David R Musich 335
The importance of the sequence/checklist 338
Team preparation – Steps I and II 351
Diagnosis and patient care – Steps III–X 357
Presurgical – Steps XI and XII 362
Postsurgical – Steps XIII–XVI 362
Feedback – Steps XVII–XVIII 364
Conclusions
References 366

The Role of Biomedical Engineers in the Design and Manufacture of 366
Customized Orthodontic Appliances 366
373
William A Brantley, Theodore Eliades 377
Introduction 377
Past research activities
Current research activities and potential future applications 380
Conclusions
References 380
381
Tissue Engineering in Orthodontics Therapy 384
388
Nina Kaukua, Kaj Fried, Jeremy J Mao 389
Introduction 389
Tissue engineering principles 389
Impact of tissue engineering on orthodontics
Orthodontics and dentofacial orthopedics as clinical motivation for tissue engineering 392
Conclusions
Acknowledgments 392
References 393
400
Corticotomy and Stem Cell Therapy for Orthodontists and Periodontists: 418
Rationale, Hypotheses, and Protocol 419
419
Neal C Murphy, Nabil F Bissada, Ze’ev Davidovitch, Simone Kucska
Introduction 422
Twentieth-century ‘OldThink’
Orthodontic ‘NewThink’: the age of the stem cell 422
Conclusions 423
Acknowledgment 423
References 424
425
The Application of Lasers in Orthodontics 427
429
Neal D Kravitz 440
Definition and laser physics
Historical perspective
Laser versus scalpel
Diode versus solid-state lasers
Choosing a proper anesthetic
Laser machine set-up
Procedures and surgical technique
Laser safety

xii  Contents Postsurgical management 442
Conclusion 442
Chapter 23 References 443
Chapter 24
Chapter 25 Implant Orthodontics: An Interactive Approach to Skeletal Anchorage 444
Index
Hyo-Sang Park 444
Introduction 445
Interactive approaches 445
Holding the molar vertical position 446
Intrusion of molars 453
Molar uprighting 461
Forced eruption 463
Surgical placement of micro-implants 467
Conclusion 468
References
470
Temporomandibular Dysfunction: Controversies and Orthodontics
470
Donald J Rinchuse, Sanjivan Kandasamy 472
Temporomandibular disorders – the evolution of controversy 474
Orthodontics and TMD 477
Centric relation controversy 477
Functional occlusion and TMD 479
Asymptomatic internal derangements – need for treatment? 480
Controversies regarding TMD treatments 480
Contemporary multidisciplinary, evidence-based treatment options 481
Conclusion
References 485

Orthodontic Treatment for the Special Needs Child 485
485
Stella Chaushu, Joseph Shapira, Adrian Becker 486
Introduction 487
Therapeutic access 489
Patient management 490
Drawing up a tentative treatment plan 497
Relapse and retention 498
Case descriptions
Conclusion 501
References

List of Contributors George J Cisneros DMD, MMSc
Professor and Chair
Nina K Anderson PhD Department of Orthodontics
Clinical Instructor New York University College of Dentistry
Department of Developmental Biology New York
Harvard School of Dental Medicine USA
Boston, Massachusetts
USA Adriana Da Silveira DDS, MS, PhD
Chief of Orthodontics
Neslihan Arhun DDS, PhD, MSc Dell Children’s Craniofacial & Reconstructive Plastic Surgery Center
Associate Professor and
Department of Conservative Dentistry Adjunct Assistant Professor
Baskent University, Faculty of Dentistry Department of Biomedical Engineering
Ankara University of Texas at Austin
Turkey Austin, Texas
USA
Ayca Arman-Ozcirpici DDS, PhD
Associate Professor Gunnar Dahlén BSc, DDS, PhD (Dr Odont)
Department of Orthodontics Professor and Chairman
Baskent University, Faculty of Dentistry Department of Oral Microbiology
Bahcelievler, Ankara Institute of Odontology
Turkey Sahlgrenska Academy at University of Gothenburg
Gothenburg
Adrian Becker BDS, LDS, DDO Sweden
Clinical Associate Professor Emeritus
Department of Orthodontics and Center for the Treatment of Ze’ev Davidovitch DMD, Cert Ortho
Craniofacial Disorders in Special Needs Individuals Professor of Orthodontics, Emeritus
The Hebrew University-Hadassah School of Dental Medicine Harvard University, Boston
Jerusalem Massachusetts
Israel USA
and
Nabil F Bissada DDS, MSD Clinical Professor
Professor and Chair Department of Orthodontics
Department of Periodontics Case Western Reserve University
Case Western Reserve University Cleveland, Ohio
School of Dental Medicine USA
Cleveland, Ohio
USA Linda A DiMeglio MD, MPH
Associate Professor
William A Brantley PhD Section of Pediatric Endocrinology and Diabetology
Professor and Director Riley Hospital for Children
Graduate Program in Dental Materials Science Indiana University School of Medicine
Division of Restorative and Prosthetic Dentistry, College of Indianapolis, Indiana
Dentistry USA
and
Department of Biomedical Engineering, College of Engineering Theodore Eliades DDS, MS, Dr Med, PhD
Ohio State University Professor and Director
Columbus, Ohio Graduate Program in Dental Materials Science
USA Center of Dental Medicine, University of Zurich
Zurich
Stella Chaushu DMD, MSc Switzerland
Associate Professor and Chair
Department of Orthodontics and Center for the Treatment of Kaj Fried DDS, PhD
Craniofacial Disorders in Special Needs Individuals Professor of Neuroscience
The Hebrew University-Hadassah School of Dental Medicine Karolinska Institutet
Jerusalem Department of Dental Medicine
Israel Huddinge
Sweden

xiv  List of Contributors Sanjivan Kandasamy BDSc, BScDent, DocClinDent, MOrthRCS,
MRACDS
Joseph G Ghafari DMD Clinical Associate Professor
Professor and Head Dental School
Division of Orthodontics and Dentofacial Orthopedics University of Western Australia
American University of Beirut Medical Center and
Beirut Centre for Advanced Dental Education
Lebanon St Louis University
St Louis, Missouri
Donald B Giddon MA, DMD, PhD, FACD USA
Associate Professor of Clinical Pediatrics
Department of Developmental Biology Nina Kaukua DDS
Harvard School of Dental Medicine Post Doctoral Fellow
Boston, Massachusetts Columbia University Medical Center
USA Craniofacial Regeneration Center, College of Dental Medicine
New York
Nadine G Haddad MD, FAAP USA
Associate Professor of Clinical Pediatrics
Indiana University School of Medicine O P Kharbanda BDS, MDS, MOrth RCS Ed, MMEd
Riley Hospital for Children Professor and Head
Section of Endocrinology and Diabetology Department of Orthodontics and Dentofacial Deformities
Indianapolis, Indiana Centre for Dental Education and Research
USA All India Institute of Medical Sciences
New Delhi
James K Hartsfield Jr DMD, MS, MMSc, PhD, FACMG, CDABO India
Adjunct Professor
Department of Orthodontics and Oral Facial Genetics Neal D Kravitz DMD, MS
Indiana University School of Dentistry Faculty, Washington Hospital Center
and Washington, DC
Department of Medical and Molecular Genetics and
Indiana University School of Medicine Baltimore College of Dental Surgery
and Dean’s Faculty, University of Maryland
Department of Orthodontics Baltimore, Maryland
University of Illinois at Chicago College of Dentistry USA
Chicago, Illinois
USA Vinod Krishnan BDS, MDS, MOrth RCS (Edin)
Professor
Mark S Hochberg DMD Department of Orthodontics
Program Director Sri Sankara Dental College
Emeritus, Pediatric Dentistry, Interfaith Medical Center Trivandrum, Kerala
and India
Attending, New York Presbyterian Hospital
New York Simone Kucska BDS, MSD
USA Kucska Facial Orthopedics
Sao Paulo, Brazil
Julie Holloway DDS, MS and
Program Director Post-Doctoral Scholar
Graduate Prosthodontics Program Los Angeles, California
Ohio State University College of Dentistry USA
Columbus, Ohio
Ohio Anne Marie Kuijpers-Jagtman DDS, PhD
USA Professor of Orthodontics
Head of Department of Orthodontics and Craniofacial Biology
Sarandeep Huja DDS, PhD Head of Cleft Palate Craniofacial Unit
Program Director Radboud University Nijmegen Medical Center
Graduate Orthodontics Program Nijmegen
Ohio State University College of Dentistry The Netherlands
Columbus, Ohio
USA

Maria J Kuriakose BDS, PhD, Cert Ortho List of Contributors  xv 
Associate Professor
Department of Cleft and Craniomaxillofacial Surgery Omur Polat Ozsoy DDS, PhD
Amrita Institute of Medical Sciences Associate Professor
Kochi, Kerala Department of Orthodontics
India Baskent University, Faculty of Dentistry
Ankara
Anthony T Macari DDS, MS Turkey
Instructor/Clinical Director
Division of Orthodontics and Dentofacial Orthopedics Carole A Palmer EdD, RD, LDN
American University of Beirut Medical Center Professor
Riad El Solh Division of Nutrition and Oral Health Promotion
Beirut Department of Public Health and Community Service
Lebanon Tufts University School of Dental Medicine
Boston, Massachusetts
Jeremy J Mao DDS, PhD USA
Professor and Zegarelli Endowed Chair
Columbia University Hyo-Sang Park DDS, MSD, PhD
Director, Center for Craniofacial Regeneration Professor and Chair
Senior Associate Dean for Research Department of Orthodontics, School of Dentistry
Columbia University College of Dental Medicine Kyungpook National University
New York and
USA Director, Orthodontic Research Center, Kyungpook National
University Hospital
Birte Melsen DDS, Dr Odont Daegu
Professor and Chairman Korea
Department of Orthodontics, School of Dentistry
Faculty of Health Sciences, Aarhus University Sherry Peter BDS, MDS, FRCS
Aarhus Clinical Professor
Denmark Department of Cleft and Craniomaxillofacial Surgery
Amrita Institute of Medical Sciences
Elliott M Moskowitz DDS, MSd, CDE Kochi, Kerala
Clinical Professor India
Department of Orthodontics
New York University College of Dentistry Ameet V Revankar BDS, MDS
New York Assistant Professor
USA Department of Orthodontics and Dentofacial Orthopedics
SDM College of Dental Sciences and Hospital
Neal C Murphy DDS, MS Dharwad, Karnataka
Clinical Associate Professor India
Departments of Orthodontics & Periodontics
Case Western Reserve University Donald J Rinchuse DMD, MS, MDS, PhD
School of Dental Medicine Professor and Graduate Orthodontic Program Director
Cleveland, Ohio USA Seton Hill University
Greensburg, Pennsylvania
David R Musich DDS, MS USA
Clinical Professor of Orthodontics
University of Pennsylvania School of Dental Medicine Lauren Schindler MS, RD
Philadelphia, Pennsylvania Senior Bariatric Dietitian
and St Alexius Hospital NewStart
Lecturer St Louis, MO
Department of Orthodontics USA
University of Illinois, School of Dentistry
Chicago, Illinois Joseph Shapira DMD
Private practice Professor and Chair
Schaumburg, Illinois Department of Pediatric Dentistry
USA The Hebrew University-Hadassah School of Dental Medicine
Jerusalem
Israel

xvi  List of Contributors Eric Lye Kok Weng BDS, MDS, FRA CDS, FAMS
Consultant
Mete Ungor DDS, PhD Department of Oral and Maxillofacial Surgery Singapore
Professor and
Head of Department of Endodontics Assistant Director
Baskent University, Faculty of Dentistry Integrated Sleep Service
Ankara Changi General Hospital
Turkey Singapore

Meade C Van Putten Jr, DDS, MS Mimi Yow BDS, FDS RCS, MSc (Orthodontics), FAMS
Director of Maxillofacial Prosthodontics Senior Consultant
The AG James Cancer Hospital and Solove Research Institute Department of Orthodontics
Ohio State University National Dental Centre
Columbus, Ohio Singapore
USA and
Clinical Associate Professor
Carlalberta Verna DDS, PhD Faculty of Dentistry
Associate Professor National University of Singapore
Department of Orthodontics, School of Dentistry Singapore
Faculty of Health Sciences, Aarhus University
Aarhus
Denmark

Neeraj Wadhawan BDS, MDS
Research Officer
Department of Orthodontics and Dentofacial Deformities
Centre for Dental Education and Research
All India Institute of Medical Sciences
New Delhi
India

Preface

The subject of this book, integrated clinical orthodontics, others seems to offer the means to clarify and confirm the
seemed initially to be a straightforward topic. After all, we identity of clinical findings in the diagnostic phase, and elu-
know that we depend on each other, in all walks of life, not cidate the road ahead, in terms of treatment plans and the
excluding orthodontics. Therefore, we thought that it choice of the most suitable mechanotherapy for the indi-
would be helpful to try to compose a publication that vidual patient.
would reflect clearly each area where orthodontists interact
with experts in other medical specialties, in an effort to The concept emerging from this book is that orthodon-
upgrade their services to their patients. tics is not merely an exercise in wire bending, but rather
a specialty leaning on many others. Interactions, whenever
Each individual who needs, seeks, or receives orthodon- indicated, between the orthodontist and other medical spe-
tic care, differs from every other individual, molecularly, cialists are a powerful tool on the way to excellence. In short,
functionally, and esthetically. This natural variability is we would like to see each and every reader of this book to
reflected in the orthodontic clinic, defining the identity of think like a healthcare professional and as a conscientious
the specialty whose experts could be beneficial to the or- member of the dental profession who wishes to bring credit
thodontist and the patient alike. Our goal has been to learn upon a high calling that has lifted itself from a questionable
from people engaged in clinical research in different medi- mechanical art to a most respected and esteemed health
cal fields, about their experience and advice on interac- service to humankind.
tions with orthodontists. These interactions stem from the
simple fact that none of us knows everything, and whether We would like to extend our heartfelt thanks to all
we like it or not, we depend on the professional opinions our contributing authors, who have generously shared
of our colleagues in other specialties, whose knowledge can their valuable knowledge and wisdom for the benefit of all
remedy the voids in our own. those who are eager to learn about the advancements in ‘sci-
ence of orthodontics’. We were excited to read the manu-
In planning the contents of this book, we immediately scripts and are hopeful that the response of our esteemed
realized that there are many fields of knowledge that can readers will be the same too. Although the chapters are
augment the diagnostic and therapeutic capabilities of the based on the contributors’ own work and experiences, all
orthodontist. In fact, we were amazed at the large number the information can be applied to similar settings across the
of these specialties, clearly reflected in the number of chap- world.
ters in this book, 25, each dedicated to a specialty whose
members interact with orthodontists. This increasingly We would also like to express our sincere gratitude to
widening scope of orthodontics is enabled by the avail- all the staff at Wiley-Blackwell, Oxford, UK, especially
ability and relative ease of electronic communication, and Sophia Joyce, Nick Morgan, Catriona Cooper, Lucy Nash,
the expanding new findings in medicine and dentistry. It and James Benefield, as well as Lotika Singha (copyeditor),
becomes increasingly difficult to command all relevant in- and Anne Bassett (project manager) whose relentless efforts
formation about emerging new and exciting fields, such as helped us to accomplish this laborious, but fulfilling, task.
tissue engineering and stem cells, and becoming aware of
ongoing progress in seemingly traditional fields, such as Vinod Krishnan
genetics, psychology, and material science. Interaction with Ze’ev Davidovitch

Editors

1

The Increased Stature of Orthodontics

Ze’ev Davidovitch, Vinod Krishnan

Summary emotional complex, by virtue of its ability to participate
actively in these functions, involving its soft (cheeks, lips,
Orthodontists treat patients with orofacial anomalies, including malocclu- and tongue) and hard (jaws and teeth) tissues. Painters,
sions, by applying mechanical forces to the crowns of teeth. These forces sculptors, and photographers have noted these features, and
are transmitted to the tissues surrounding the roots of the teeth, enticing frequently, when creating images of human faces, included
their cells to remodel these tissues, thereby enabling the teeth to move the rest of the body, or at least the torso, in their art work,
to new, preferred positions. Like any other tissues and organs in the demonstrating acceptance of the principle that the face and
human body, dental tissues and cells are controlled by the nervous, the rest of the body are one unit. The specialty of ortho-
immune, vascular, and endocrine systems, as well as by factors such as dontics is taught predominantly as a field of endeavor dedi-
psychological stress, nutrition, medications, and local and systemic dis- cated to the improvement of orofacial esthetics and
eases. Since the jaws are integral parts of the body as a whole, ortho- function. Consideration of biological principles and con-
dontic diagnosis must include detailed information on any deviation from straints is shadowed by the desire of both the patient and
general health norms, and these data should be reflected in the treatment his/her orthodontist to achieve noticeable improvement in
plan. Therefore, when specific pathologies are identified, an interaction the position and location of the malpositioned crown(s),
with the appropriate healthcare provider who is treating the patient ignoring the fact that the crowns are anchored in the jaws
should occur, or a referral made to another specialist. The advice obtained by their roots, which are surrounded by tissues that act and
from these experts can have a substantial impact on the orthodontic react like any other organ to any local or systemic factor
diagnosis and treatment plan. Continuing advances in medicine and den- that comes their way. This situation is similar to an iceberg,
tistry increase the scope, importance, and value of these interactions. This visible partially above the water surface, but invisible
introductory chapter discusses the need and rationale for interactions in under it.
specific situations, and this book includes details of conditions that require
advice from specific specialists. The focus on this expanding scope is Malocclusions are situations where individual teeth or
derived from the notion that biology plays a pivotal role in orthodontics, entire dental arches are positioned in undesirable locations,
and that pertinent information regarding the health status of individual either esthetically or functionally. The goal of orthodontics
candidates for orthodontic treatment might have long-lasting effects on is to correct or minimize deviations from accepted normal
the course and outcomes of orthodontic treatment. characteristics of dental occlusion, orofacial function, and
esthetics. We tend to focus on these deviations from nor-
Introduction malcy as the main target of our specialty, while keeping
other health-related issues far in the background, some-
Facial esthetics, balance, and harmony, and/or their absence, times behind the horizon, as if a malocclusion exists in a
have attracted attention from time immemorial, by artist vacuum, detached from the rest of the body. Maintenance
and art viewer alike. Facial expressions can readily reflect of this outlook may, however, jeopardize the quality of
various moods, emotions, and feelings, thereby conveying orthodontic diagnosis, treatment plan, outcome, and long-
unspoken messages from person to person. The mouth is term maintenance of the corrected malocclusion. What is
an essential component of this anatomical–physiological–

Integrated Clinical Orthodontics, First Edition. Edited by Vinod Krishnan, Ze’ev Davidovitch.
© 2012 Blackwell Publishing Ltd. Published 2012 by Blackwell Publishing Ltd.

2  Integrated Clinical Orthodontics

required for attainment of optimal results in orthodontics ment. The existence of rapid communication systems
is broadening of its scope, to include other specialties, enables an orthodontist to easily seek advice from other
dental and medical, that may expose etiological factors, and specialists, leading to the crafting of diagnoses and treat-
biological processes that could determine the nature of the ment plans tailored specifically for each individual patient.
cellular/tissue response to mechanotherapy. In short, we These systems are also very useful in fostering strong
should not treat a malocclusion, but rather a person with a doctor–patient trust, increasing cooperation and improv-
malocclusion (McCoy, 1941; Kiyak, 2008). ing outcomes.

Presently, orthodontics is viewed by the general popula- Likewise, recent advances in material science, metallurgy
tion as a field occupied mainly by concerns about facial and biomedical engineering have introduced an increasing
esthetics, and limited to the application of ‘braces’ to array of alloys, capable of generating a wide spectrum of
crooked teeth. This image has been cultivated and nurtured mechanical forces. A continuous interaction between the
by many members of the orthodontic specialty, because it orthodontist and these engineers has already produced
simplifies their lives by highlighting the known fact that major changes in the design of orthodontic brackets, and
teeth move when subjected to mechanical forces. This the composition of the metallic and nonmetallic wires that
outlook is deeply embedded in the curricula of the majority generate the proper orthodontic forces, while controlling
of the orthodontic educational/training programs around factors such as friction and strain. This interaction is a
the world. Orthodontic residents are made to believe, at fertile ground for the development of new appliances
least subconsciously, that correcting a malocclusion in a capable of engendering optimal tooth movement, biologi-
human being is just as easy as moving metallic teeth through cally and mechanically, for each patient. Moreover, these
the warm, soft wax of a typodont (Davidovitch and engineers are crucial participants in the design and manu-
Krishnan, 2009). Furthermore, this attitude has encouraged facturing of the multiple prototypes of metallic implants
general dentists to engage in the practice of orthodontics and mini-implants, which are used for the creation of
without obtaining proper education that would qualify intraoral anchorage, thereby taking away this responsibility
them for this task. An example of a poor outcome of such from teeth and thus avoiding altogether any undesirable
treatment is seen in Figure 1.1. However, orthodontics, tooth movement.
which had been viewed until recently as being mainly a
technique-oriented profession, has actually evolved into a The pioneers of modern orthodontics were pathfinders
comprehensive specialty, with a rapidly expanding scope, in a field full of challenges and obstacles. Those leaders
increasingly interacting with experts in biology, medicine, utilized the best therapeutic tools available for eliminating
dentistry, engineering, and computer science. These inter- malocclusions, paving the way for greater achievements by
actions can provide the orthodontist with important infor- their successors. Edward H Angle, the ‘father of modern
mation pertaining to individual patients that may lead to orthodontics’, advocated at the end of the nineteenth
modifications in the diagnosis and treatment plans. century the inclusion of basic medical sciences, such as
anatomy, physiology, and pathology, in the curriculum
Voluminous expansion of the scientific and clinical bases designed for educating dentists as specialists in orthodon-
of orthodontics is occurring in various directions, biologi- tics. He apparently saw clearly the functional connection
cal and technical. The role of biology in the diagnosis, treat- between the head and the rest of the body. Three decades
ment planning, and treatment of individual patients is on, one of his students, Albert Ketcham (1929), in attempt-
becoming increasingly clear (Cartwright, 1941; Davidovitch ing to elucidate the reasons for dental root resorption
and Krishnan, 2009). An orthodontist may be an expert in (a major undesirable side effect of tooth movement),
mechanics, but he/she is not a nutritionist, psychologist, concluded that the etiology is associated with the patient’s
pediatrician, endocrinologist, primary care physician, oral metabolism. In the following years, resorption of roots
and maxillofacial surgeon, endodontist, prosthodontist, or was attributed to factors such as nutritional deficiencies,
any other medical and/or dental specialist. Therefore, it hormonal fluctuations, genetic predisposition, and psycho-
seems only prudent to request advice from other specialists logical stress. All these factors point to the notion that tissue
whenever a condition is recognized in a person seeking remodeling that facilitates tooth movement is dependent,
orthodontic treatment, or in a patient who is already being at least in part, on the unique pathophysiological profile
treated. of the individual patient. Detailed information on this
biological profile may be obtained from a number of
The reality is that people who possess malocclusions may different healthcare providers familiar with individual
also have pathological conditions that could significantly patients.
impact the course and outcome of orthodontic treatment.
This probability creates a need to consult and interact with However, despite the recognition of the importance of
other specialists familiar with an individual patient, or with life sciences in orthodontic education and practice, consid-
the health problem afflicting this individual. Moreover, erable emphasis is still being placed on the mechanical
some people may have communicable diseases that may aspect of this specialty. Consequently, conditions such as
endanger the well-being of others who are in their environ- excessive root resorption are labeled as idiopathic, unpre-

The Increased Stature of Orthodontics  3 

Figure 1.1  Poorly executed orthodontic treatment by a general practitioner. Ignoring the absence of mandibular central incisors, the practitioner extracted all
the second premolars but was then unable to close the spaces entirely, ending with excessive overjet and a very deep bite.

dictable and an ‘act of God’. These explanations fly in the resorption or bending of the alveolar bone, or by both proc-
face of the long-recognized principle of the intimate union esses. Farrar’s comment was surprisingly correct, although
between biology and mechanics in orthodontic therapy. it was based on empirical evidence. Experimental evidence
This proximity was first suggested by Farrar (1888), who supporting Farrar’s hypothesis was provided by Sandstedt
speculated that tooth movement is facilitated by either (1904–5), and by Baumrind (1969). While Sandstedt used

4  Integrated Clinical Orthodontics

histological sections to demonstrate that paradental cells A similar malocclusion in a different patient may read as
are responsible for the force-induced tissue remodeling, follows: ‘RM is a 14-year-old boy, entering the pubertal
Baumrind confirmed in experiments on rats that ortho- growth spurt, who has type 1 diabetes, allergies, and asthma,
dontic forces indeed bend the alveolar bone. with a Class II Division 1 malocclusion, a steep mandibular
plane, and an 8 mm overjet.’ This concise but detailed diag-
The broadening scope of orthodontics nosis implies that the patient is growing and has health-
related issues that may overshadow the orthodontic problem
The chief purpose of orthodontic treatment is to assist and its treatment outcome. Systemic issues of this nature,
nature in the proper development of the orofacial system involving the immune, endocrine, and vascular systems,
in growing children, and correct malocclusions in young may alter the response of cells surrounding teeth to applied
and adult patients. Ideally, orthodontics should be prac- mechanical stress, modify the velocity of tooth movement
ticed in a facility that houses all other medical specialists, and contribute to the creation of undesirable side effects to
such as a hospital, or a large group practice. In such an orthodontic treatment, such as irreversible loss of alveolar
environment, reaching various experts and obtaining their bone and shortening of dental roots. Moreover, if medical
advice about health-related problems of individual ortho- and/or socioeconomic problems are ignored, and are
dontic patients may be accomplished with relative ease. allowed to persist, maintenance of the corrected malocclu-
Specialists such as primary care/family physicians, ortho- sion may be jeopardized. Therefore, in the case of RM, it
pedists, surgeons, psychologists and nutritionists may be may be advisable for the orthodontist to communicate with
within walking distance from the orthodontic clinic. the patient’s pediatrician, endocrinologist, and nutritionist
However, the widespread network of electronic communi- prior to solidifying the diagnosis and treatment plan.
cations today has enabled an orthodontist to refer a patient
for consultation and receive the specialist’s opinion in a The orthodontic patient as a human being
timely fashion, without dependence on geographical prox-
imity or venue location. Orthodontists not only see young individuals, who are
ready to face the world with a lot of enthusiasm and con-
Contemporary orthodontics is a fusion of biology and fidence, but also adult patients with various needs and
mechanics, starting with the process of diagnosis, which is expectations. In some instances, patients may be having
based on estimating and documenting the extent of maloc- psychosocial issues, and may seek orthodontic therapy in
clusion, as well as asking: ‘Who is the patient, biologically?’ an attempt to alleviate their personality deficits, improve
This question must be answered before any plans of tooth their social status and find solutions to problems in their
movement can be contemplated. The presence of any sys- professional and personal life. It is extremely important to
temic or local pathological condition may cause significant realize that every patient considered for treatment is an
alterations in the orthodontic therapeutic plans for any and individual with a metabolic profile and physiological traits
every individual patient, regardless of age or gender. A com- unique to him/her (Bartley et al., 1997) even though all
prehensive orthodontic diagnosis should start with a humans share similar genetic, anatomical, physiological,
detailed presentation of the patient’s biological profile, and biochemical bases. The interindividual differences may
including all conditions that may impact on mechano- arise from physical, social, ethnic, psychological, and meta-
therapy. This segment of the diagnosis is followed by a bolic variations, among other factors. It is important to
detailed description of the malocclusion. The biological realize that orthodontic treatment is provided to vital
segment is the part where interaction with specialists in tissues that respond in a similar fashion in all patients.
various medical fields is expressed, and is later reflected in However, the extent, duration, and outcome of this response
the crafting of an individual treatment plan. A brief example are frequently dependent on biological factors only remotely
of such a diagnosis is as follows: ‘AZ is a 34-year-old female related to the malocclusion at hand.
nurse, mother of a two children, with multiple sclerosis that
started 5 years ago, with a history of familial neuropathies. The pattern and timing of craniofacial growth and devel-
She has a Class II Division 1 malocclusion, with a steep opment events are intimately associated with somatic
mandibular plane, an 8° ANB angle, and a 12 mm overjet’. growth-related functions, controlled and regulated by a
This diagnosis is a presentation of the main systemic and myriad of chemical and physical factors, of internal and
orofacial findings, which pave the way, together, to a proper external origin, interacting with target cells in many or all
treatment plan. For the sake of providing the best treatment organs and systems. This complex reality faces every ortho-
plan for AZ, it would be beneficial to seek the advice of the dontist, as well as any other healthcare provider. It is rather
other specialists who take care of her, such as her personal unrealistic to expect that any one individual, in any medical
physician, neurologist, and nutritionist. Their opinions specialty, would be able to comprehend, manage, and mem-
may turn out to be valuable in guiding the orthodontist orize all this voluminous knowledge. Hence the need for
toward a treatment plan that would be optimal and practi- the orthodontist to keep abreast of new developments in
cal for this individual patient. the entire field of medicine, and to interact with members

The Increased Stature of Orthodontics  5 

of other specialties whenever a situation arises that requires elsewhere in the body is the main reason for interacting
input from other experts. with physicians, nutritionists, psychologists or other experts
in healthcare provision.
One fundamental interaction in this formula is between
orthodontists, who move teeth with mechanical forces, and Many individuals seeking orthodontic care have systemic
the experts who create the means to generate these forces: ailments, such as asthma, and are usually already under
biomedical and metallurgical engineers. The requirement treatment for these conditions at the time of their ortho-
for a perpetual interaction between experts in these entities dontic diagnosis appointment(s). This treatment often
is because orthodontic tooth movement requires close entails the use of various prescription and/or over-the-
interaction between the biological and the mechanical envi- counter medications. Some of these medications may have
ronments (Krishnan and Davidovitch, 2006a; Meikle, 2006) insignificant effects on the process of tissue remodeling
and, even in a healthy patient, the response to orthodontic evoked by the orthodontic forces, but others, such as ster-
forces can vary from time to time, because the duration of oidal and nonsteroidal anti-inflammatory drugs, anti-
treatment is often measured in years. In addition, the pres- cancer medications, immune suppressors, statins, and
ence of an underlying ailment that affects the physiological anti-osteoporotic medications, may reach the cells in and
condition may alter the nature of the acute and chronic around moving teeth by exiting, in the plasma, through
inflammation that are core events in tooth movement, and capillaries that have become hyperpermeable by the applied
modify craniofacial growth and development (Alvear et al., stress (Krishnan and Davidovitch, 2006b). It is, therefore,
1986). Cellular signaling molecules generated either in the important to record all the medications taken regularly by
vicinity of the periodontal ligament or in distant sites have a patient before the onset of orthodontic treatment, as well
the potential to disrupt tooth movement by altering the as during the course of therapy. Once a complete list of
levels of biomolecules in the local biological environment medications taken regularly by a patient is obtained, it is
of the periodontal ligament (Krishnan and Davidovitch, essential to search for information about their desirable and
2006b). undesirable effects. This information can be readily found
on the internet and in current pharmacopeias. An example
The patient’s biological status – does it of a profound effect of a nonsteroidal anti-inflammatory
influence orthodontic treatment? drug on cells involved in orthodontic tissue remodeling is
demonstrated in Figure 1.2, showing the mesially-located,
Due to the uniqueness of every individual patient’s biology, stretched PDL and alveolar bone surface lining cells of a
it is imperative for the orthodontist to create and maintain maxillary cat canine that had been moved distally for 24h,
open communication channels with practitioners in every with a force of 80 g. The tissue sections were stained immu-
medical field. Patients may be referred for consultation to nohistochemically for prostaglandin E2, a ubiquitous
their personal physician, or to experts in specific areas, such inflammatory mediator. A section taken from a control cat
as endocrinology, neurology, immunology, genetics, metab- untreated by the nonsteroidal anti-inflammatory drug,
olism, pulmonology, nutrition, psychology, and infectious indomethacin, shows cells intensely stained for PGE2, while
diseases. Each organ or tissue system in a pathological state a section obtained from an indomethacin-treated cat dem-
may have profound effects on paradental cells and tissues, onstrates a marked reduction of staining intensity, suggest-
by transferring signal molecules through the vascular ing that this drug may have a profound effect on tooth
system to any tooth being moved, and all the cells sur- movement.
rounding it.
Nutrition may play an important role in determining
Inflammation is a central coordinator of orthodontic the pattern and course of tooth movement (Palmer, 2007).
tooth movement, and as such, it ushers leukocytes and A modern diet consists of proper amounts of proteins,
plasma out of the mechanically stressed capillaries, which carbohydrates, lipids, vitamins, and trace elements.
become hyperpermeable in reaction to the release of However, within the same community, marked differences
vasoactive neurotransmitters from the strained nerve ter- between individuals may be found in the relative propor-
minals. In this fashion, leukocytes that had become primed tion of each dietary component, and even greater differ-
in remote diseased organs can enter strained dental and ences are known to exist between members of diverse
paradental tissues, and interact with cells carrying receptors communities, despite their geographical proximity. Some
for signaling molecules synthesized by the migratory items in the diet may be essential for eliciting a vigorous
immune cells. Experiments with human periodontal liga- cellular response to mechanical forces. For example, vitamin
ment (PDL) fibroblasts in vitro, revealed that these cells C is an essential co-factor in the synthesis of collagen by
respond readily to cytokines, growth factors, colony stimu- fibroblasts, and vitamin D3 is a key regulator of the mobi-
lating factors and chemo-attractant signals, all of which are lization of calcium into and out of the intestine, kidney, and
produced and released by the newly arrived leukocytes skeleton. Proteins provide the amino acids needed for
(Saito et al., 1990a,b). This intimate correlation between building and remodeling tissues surrounding moving teeth;
tooth movement and pathological conditions that happen carbohydrates supply the energy required for all cellular

6  Integrated Clinical Orthodontics

(a) (b)

Figure 1.2  Immunohistochemical staining for prostaglandin (PG) E2 in sagittal sections, 5 µm thick, of maxillary canines of 1-year-old cats, after 24 hours of
distal movement by an 80 g translatory force. (a) Periodontal ligament (PDL) tension site of control cat, showing distinct staining in alveolar bone osteoblasts.
(b) PDL tension site of a cat injected subcutaneously with indomethacin, 5 mg/kg, at the time of appliance activation. The staining intensity for PGE2 in osteoblasts
and PDL cells is light.

activities, and lipids are a critical part of every cell’s plasma central or peripheral, administration of orthodontic forces
membrane. may exacerbate the neurological condition, and/or be
affected by it. Moreover, medications taken by these patients
Some dietary components may be detrimental to the may also alter the pattern of tissue response to orthodontic
patient’s health and well-being, and have a negative effect forces (Krishnan and Davidovitch, 2006b). Therefore, it
on dental and paradental tissues. In the case of alcohol, its may be prudent to seek the advice of the neurologists treat-
chronic excessive consumption may cause dental root ing such patients.
resorption in orthodontic patients, by causing liver cirrho-
sis, disrupting the hydroxylation of vitamin D3 in the liver, The immune system is a network of biological structures
thereby evoking increased production of parathyroid and processes within an organism that protects against
hormone (PTH), necessary for the maintenance of calcium disease by identifying and killing pathogens and tumor
homeostasis (Ghafari, 1997). This hormone is implicated cells. It detects a wide variety of agents, from viruses to
in the resorption of mineralized tissues, including dental parasitic worms, and needs to distinguish them from the
roots. For these reasons it may be helpful to obtain detailed organism’s own healthy cells and tissues in order to func-
information about the dietary habits of every patient prior tion properly. Detection is complicated as pathogens can
to the onset of orthodontic treatment. An evaluation of evolve rapidly, producing adaptations that avoid the
individual daily diets by a qualified nutritionist may supply immune system and allow the pathogens to successfully
the orthodontist with important clues regarding expecta- infect their hosts (Abergerth and Gudmundsson, 2006).
tions of individual tissue responses to orthodontic The immune system provides the leukocytes required for
mechanotherapy. the induction and maintenance of inflammation, which is
the mechanism whereby tissue remodeling facilitates tooth
Regulation of mammalian body functions is dominated movement. Disorders of the immune system, such as
to a large extent by three systems: the nervous, immune, immunodeficiency that occurs when the immune system is
and endocrine systems. Persons seeking orthodontic care less active than normal, result in recurring and life-
sometimes have ailments that affect one or more of these threatening infections. Immunodeficiency can either be the
systems. Treating such patients orthodontically with little result of a genetic disease, such as severe combined immu-
consideration for their systemic abnormalities may result nodeficiency, or secondary to pharmaceutical therapy or an
in some unpleasant surprises for the patients, as well as for infection (such as the acquired immune deficiency syn-
their orthodontists. For example, a patient with an existing drome (AIDS), which is caused by the retrovirus human
condition such as multiple sclerosis may develop trigeminal immunodeficiency virus (HIV)). In contrast, autoimmune
neuralgia early in the course of orthodontic treatment, diseases result from a hyperactive immune system attacking
because of the acute pain generated every time the ortho- normal tissues, as if they were foreign organisms. Common
dontic appliance is activated. The pain may even be ampli- autoimmune diseases include Hashimoto thyroiditis, rheu-
fied because of the direct contact between the denuded, matoid arthritis, diabetes mellitus type 1 and lupus ery-
unmyelinated trigeminal nerve fibers. In cases such as this, thematosus.Figure 1.3 shows intraoral views in a 39-year-old
and in patients with other neurological diseases, either

The Increased Stature of Orthodontics  7 

(a) (b)

(c) (d)

Figure 1.3  A malocclusion in a 39-year-old man with a number of systemic diseases. (a) Frontal view of the dentition, demonstrating a midline shift and
bilateral posterior crossbite. (b, c) Left and right views of the dentition, showing spaces resulting from prior tooth extractions. Tipping of teeth into the extraction
sites is visible in both dental arches. (d) The maxillary periapical radiograph reveals severe shortening of the premolar and molar roots.

man with a history of diabetes mellitus type 1, Hashimoto integrative center for the endocrine and autonomic nervous
thyroiditis and depression. He had an obvious malocclu- systems, controls the function of endocrine organs by
sion and his systemic diseases were being treated by a neural and hormonal pathways.
variety of medications. In view of the multiplicity of dis-
eases and the numerous medications taken by this patient, Application of orthodontic forces increases the blood
the patient’s physician recommendation was to refrain flow into the tooth and the paradental tissues (Kvinnsland
from orthodontic treatment. The decision to not consider et al., 1989; Ikawa et al., 2001) and their capillaries become
orthodontics was reached on the basis of input from the hyperpermeable, fostering plasma extravasation. This local
patient’s physician, dentist, and a prosthodontist. alteration in the vascular system can cause an increase in
the tissue concentration of hormones, of which some, like
The endocrine system is a system of glands, each of parathyroid hormone, calcitonin and thyroxin are known
which secretes a specific type of hormone to regulate the to regulate bone metabolism (Copp and Cheney, 1962;
body and act as an information signal system, much like Mundy et al., 1976; Parfitt, 2003; Martin, 2004; Poole and
the nervous system. A hormone is a chemical transmitter Reeve, 2005). Figure 1.4 presents photomicrographs of the
released from specialized cells into the bloodstream, which alveolar bone and PDL, as seen in sections stained immu-
transports it to specialized organ-receptor cells that respond nohistochemically for 3′, 5′-adenosine monophosphate
to it. Hormones regulate many functions of an organism, (cyclic AMP or cAMP). The sections were obtained from
including mood, growth and development, tissue function three young adult cats. Figure 1.4a is from an untreated
and metabolism. Together with the nervous system, the (control) cat and shows mild cellular staining intensity for
endocrine system regulates and integrates the body’s meta- cAMP near a maxillary canine. Figure 1.4b is from a cat
bolic activities. The endocrine system meets the nervous whose maxillary canine was subjected to 24 hours of distal
system at the hypothalamus. The hypothalamus, the main movement. This figure is from the zone of tension in the

8  Integrated Clinical Orthodontics

(a) (b)

(c) (d)

(e) (f)

Figure 1.4  Immunohistochemical staining for cAMP in sagittal sections, 5 µm thick, of maxillary canines of 1-year-old cats after 24 hours of distal movement
by an 80 g translatory force. (a) Osteoblasts and (b) periodontal ligament (PDL) fibroblasts from a control cat (no orthodontic force). (c) Osteoblasts and
(d) fibroblasts in PDL tension site (cat received orthodontic force, but no parathyroid hormone (PTH)). (e) Osteoblasts and (f) fibroblasts in PDL tension site. This
cat received orthodontic force, and a subcutaneous injection of PTH, 30 IU/kg, at the time of the appliance activation. The intensity of staining for cAMP is light
in the untreated control animal, pronounced in the animal that was treated by force alone, and was very intense in the animal treated by force and PTH.

PDL, demonstrating intense staining for cAMP, resulting this figure, the cells are stained extremely dark, reflecting a
from the orthodontic force. Figure 1.4c was derived from a high concentration of cellular cAMP. Since this cyclic nucle-
cat that had been treated in the same manner as the one otide represents cellular activation by extracellular signals,
shown in Figure 1.4b, and in addition received a subcutane- it is reasonable to conclude that the biological response to
ous injection of PTH, 30 IU/kg, 2h before euthanasia. In orthodontic forces may be sensitive to hormonal concen-

The Increased Stature of Orthodontics  9 

trations in the blood. These concentrations are modified Such is the case in caring for patients with orofacial clefts
significantly by pathological conditions that develop in spe- and other craniofacial anomalies, where teams of experts
cific endocrine glands, suggesting that an opinion of an convene to discuss each patient’s individual needs in a
endocrinologist about the patient’s hormonal profile could detailed and carefully coordinated sequence. These teams
be very helpful in crafting a proper orthodontic diagnosis include experts in pediatrics, plastic surgery, psychology,
and treatment plan. social work, nutrition, dentistry, and orthodontics. A
similar team approach is adopted for the treatment of
Orthodontists treat human beings, who sometimes are adults who require reconstructive treatment. The team in
unable or unwilling to acknowledge and comply with this case may include a general dentist and specialists in
their share of responsibility and effort dictated by the treat- periodontics, endodontics, maxillofacial surgery, prostho-
ment regimen. Frequently, such behavioral patterns stem dontics, and orthodontics.
from psychological stresses, rooted in genetic, developmen-
tal, and/or environmental etiologic factors. Hence, psychol- The orthodontist’s professional wish-list includes a com-
ogy is apparently a crucial element in determining and fortable, painless experience for all patients, efficient treat-
forecasting the degree of success or failure of orthodontic ment of short duration, avoidance of iatrogenic damage,
treatment. Psychology is a field that focuses on studying and a guarantee that the teeth have been moved to their
the mind. Psychologists attempt to understand the role best position, from where there is no relapse. The duration
of mental functions in individual and social behavior, of tooth movement may be shortened significantly by deco-
while also exploring underlying physiological and neuro- rtication of the alveolar bone, leading to release of stem cells
logical processes. Psychologists study such topics as percep- from the bone marrow, and the engineering of new tissues
tion, cognition, attention, emotion, motivation, brain (Wilcko et al., 2009).
functioning (neuropsychology), personality, behavior, and
interpersonal relationships. Deviation from the norm in Conclusions
any of these areas may harbor the seed of failure of ortho-
dontic treatment. A review of records of about 1100 patients Treatment of a malocclusion requires high technical skills
who had completed orthodontic treatment revealed that and a thorough comprehension of biological sciences,
those who had been diagnosed before the onset of treat- because teeth transfer the applied orthodontic force to their
ment as having had psychological problems, such as mood surrounding tissues, where strained cells remodel the PDL
swings and anxiety, displayed a high risk of developing and alveolar bone, allowing the teeth to move to new posi-
excessive root resorption during the course of treatment tions. The biological component reflects the nature of the
(Davidovitch et al., 2000). This undesirable outcome could anticipated clinical response, and highlights the plethora of
have been the result of alterations in the hypothalamic– differences between all patients. These physiological and
pituitary–adrenal axis, caused by the psychological prob- pathological differences may have profound effects on the
lems. Another unexpected side effect of orthodontic outcomes of treatment. Detailed descriptions of these con-
treatment in a psychologically stressed patient is alopecia ditions may be found in the library or on the internet, but
totalis (Davidovitch and Krishnan, 2008) (Figure 1.5a–g). in addition it is advisable to communicate effectively
Apparently, the mind is an important determinant of the with each patient, and with all experts who have examined
degree of success of orthodontic treatment. Therefore, it and treated the patient previously. These specialists can
seems advantageous to interact with a psychologist when- share invaluable information about their own observations
ever a psychological issue is diagnosed, both before and of the patient’s biological and therapeutic profile. Such
during treatment. details should be included in the diagnosis, and reflected
in the treatment plan, that may differ from a plan
Interactions between dentists who practice one or more that addresses only the morphological features of a
specialties are almost axiomatic. Patients with malocclu- malocclusion.
sions are frequently being referred to an orthodontist for
an initial examination and assessment of the degree of need The continuous evolution in material and biological
for orthodontic care. The referring person may be a general sciences will strengthen further the interactions between
dentist who controls the dental health of the patient and orthodontists and other healthcare specialists, leading
his/her family, a periodontist, a pedodontist or another the way toward sustainable corrections of malocclusions
dental specialist. After examining the patient, the ortho- and craniofacial anomalies. These unfolding advances will
dontist informs the referring dentist about his/her findings continue to reduce the distance to the elusive target of
and recommendation, and whenever necessary, they coor- optimal orthodontics. The common thread that unifies
dinate the timing of various treatment phases. However, specialists in various disciplines is the desire to share,
sometimes elimination of a complex malocclusion, which contribute to and participate in efforts to improve every­
involves the teeth, their surrounding tissues, as well as the body’s body and spirit, a universal goal that knows no
facial muscles and skeleton, requires the construction of a boundaries.
comprehensive treatment plan by a number of specialists.

10  Integrated Clinical Orthodontics

(a)

(b)
Figure 1.5  (a)  Pre-treatment extra- and intraoral photograph of MV, at age 12 years and 10 months. Note good symmetry, smiling picture revealing maxillary
midline is shifted 3.5 mm, a convex profile. Teeth in occlusion show a deep anterior overbite (80–90%) and spaces between the maxillary incisors. The maxillary
midline is shifted 3.5 mm to the right. On the right side, the buccal occlusion is neutral and spaces are seen between the maxillary incisors and mesial to the
canine. Left side shows a Class II Division 1 molar relationship as well as spaces between the maxillary incisors and mesial to the canine. Occlusal view of maxil-
lary dental arch shows a parabolic shape, spaces between the anterior teeth from canine to canine, and distolabial rotations of both central incisors. Mandibular
dental arch shows a U-shape, without any spacing or crowding of teeth. (From Davidovitch Z, Krishnan V (2008), courtesy of Quintessence Publishing Co Inc,
Chicago.) (b)  Pre-treatment lateral cephalogram demonstrating normal anteroposterior and vertical relationships between the jaws, a favorable inclination of
the anterior cranial base and the palatal and mandibular planes, and a deep overbite in the incisor region. The panoramic radiograph reveals all teeth to be
present and normal dental development. (From Davidovitch Z, Krishnan V (2008), courtesy of Quintessence Publishing Co Inc, Chicago.)

The Increased Stature of Orthodontics  11 

(c)

(d)
Figure 1.5  (Continued ) (c)  MV’s dentition 1 year after the onset of orthodontic treatment. Frontal view and both left and right lateral views demonstrated
accumulation of dental plaque and food debris in the canine and premolar regions between the brackets and the gingival margin. Occlusal view shows spaces
between the maxillary canines and lateral incisors. (From Davidovitch Z, Krishnan V (2008), courtesy of Quintessence Publishing Co Inc, Chicago.) (d)  Photograph
of MV in October 1991, 9 months after the beginning of orthodontic treatment, 1 month after he lost all his scalp hair (alopecia totalis). (From Davidovitch Z,
Krishnan V (2008), courtesy of Quintessence Publishing Co Inc, Chicago.)

12  Integrated Clinical Orthodontics

BOYS: 2 TO 18 YEARS NAME RECORD #
PHYSICAL GROWTH
NCHS PERCENTILES*

MOTHERS STATURE FATHERS STATURE 11 12 13 14 15 16 17 18 77

DATE AGE STATURE WEIGHT COMMENT AGE (YEARS) 16 76

13 14 15 190 75 Ross
85 74 Growth &
80 185 73 Development
Progam
72
2 3 4 5 6 7 8 9 10 75 180 71
50 70
62
61 155 175 69
60 25 68
59 150
58 170 67
57 145 10 66
56 5 165 65
55 140
54 64
53 135
52 160 63
51 130
50 62
49 125 155 61
48 cm In
47 120
46 S 95 210
45 115 T
44 A 90 200
43 110 T
42 U 85 190
41 105 R 180
40 E
39 100 80
38 170
37 95
36 75
35 90 160
34
70
85 150
33
32 80 65
31 140
30 75
29 60 130
In cm
55 120
40
50 110

45 100

W 40 90

E 80
35
I

G 70
30
H
T 60

25

50

20
40

15 AGE (YEARS) 15
30 30
Ib kg
kg Ib
2 3 4 5 6 7 8 9 10 11 12
17 18

(e)

Figure 1.5  (Continued ) (e)  Physical growth (stature) curve of MV, revealing the somatic growth inhibitory effects of the corticosteroid treatment that was
implemented in an attempt to restart new hair growth. The hormonal treatment failed to stimulate hair growth. (From Davidovitch Z, Krishnan V (2008), courtesy
of Quintessence Publishing Co Inc, Chicago.)

The Increased Stature of Orthodontics  13 

(f)

(g)
Figure 1.5  (Continued ) (f)  Photograph of MV taken in December 1993, 11 months after the completion of his orthodontic treatment and 1.5 years of treatment
with vitamin D3. Apparently, this treatment mode was successful in restoring hair growth. (From Davidovitch Z, Krishnan V (2008), courtesy of Quintessence
Publishing Co Inc, Chicago.) (g)  Extra- and intraoral photographs of MV taken in August 1999. His hair remained intact. (From Davidovitch Z, Krishnan V (2008),
courtesy of Quintessence Publishing Co Inc, Chicago.)

14  Integrated Clinical Orthodontics

References Krishnan V, Davidovitch Z (2006a) Cellular, molecular, and tissue-level
reactions to orthodontic force. American Journal of Orthodontics and
Agerberth B, Gudmundsson GH (2006) Host antimicrobial defence pep- Dentofacial Orthopedics 129: 469, e1–32.
tides in human disease. Current Topics in Microbiology and Immunology
306: 67–90. Krishnan V, Davidovitch Z (2006b) The effect of drugs on orthodontic
tooth movement. Orthodontics and Craniofacial Research 9: 163–71.
Alvear J, Artaza C, Vial M, Guerrero S, et al. (1986) Physical growth and
bone age of survivors of protein-energy malnutrition. Archives of Kvinnsland S, Heyeraas K, Ofjord ES (1989) Effect of experimental tooth
Disease in Childhood 61: 257–62. movement on periodontal and pulpal blood flow. European Journal of
Orthodontics 11: 200–5.
Bartley AJ, Jones DW, Weinberger DR (1997) Genetic variability of human
brain size and cortical gyral patterns. Brain 120(Pt 2): 257–69. Martin TJ (2004) Does bone resorption inhibition affect the anabolic
response to parathyroid hormone? Trends in Endocrinology and
Baumrind S (1969) A reconsideration of the property of the pressure Metabolism 15: 49–50.
tension hypothesis. American Journal of Orthodontics 55: 12–22.
McCoy JD (1941) The general health benefits of orthodontic treatment.
Cartwright FS (1941) Extending the scope of orthodontics. American American Journal of Orthodontics and Oral Surgery 27: 369–78.
Journal of Orthodontics and Oral Surgery 27: 394–8.
Meikle MC (2006) The tissue, cellular, and molecular regulation of ortho-
Copp DH, Cheney B (1962) Calcitonin – a hormone from the parathyroid dontic tooth movement: 100 years after Carl Sandstedt. European
which lowers the calcium-level of the blood. Nature 193: 381–2. Journal of Orthodontics 28: 221–40.

Davidovitch Z, Krishnan V (2008) Adverse effects of orthodontics. Mundy GR, Shapiro JL, Bandelin JG, et al. (1976) Direct stimulation of
A report of two cases. World Journal of Orthodontics 9: 268. bone resorption by thyroid hormones. Journal of Clinical Investigatoins
58: 529–34.
Davidovitch Z, Krishnan V (2009) Role of basic biological sciences in
clinical orthodontics: a case series. American Journal of Orthodontics and Palmer CA (2007) Effective communication in dental practice. In: Diet,
Dentofacial Orthopedics 135: 222–31. Nutrition and Oral Health, 2nd edn. Upper Saddle River, NJ: Pearson,
pp 409–52.
Davidovitch Z, Lee YJ, Counts AL, et al. (2000) The immune system pos-
sibly modulates orthodontic root resorption. In: Z Davidovitch, J Mah Parfitt AM (2003) Parathyroid hormone and periosteal bone expansion.
(eds) Biological Mechanisms of Tooth Movement and Craniofacial Journal of Bone and Mineral Research 17: 1741–3.
Adaptation. Boston, MA: Harvard Society for the Advancement of
Orthodontics, pp. 207–17. Poole K, Reeve J (2005) Parathyroid hormone–a bone anabolic and cata-
bolic agent. Current Opinion in Pharmacology 5: 612–17.
Farrar JN (1888) Irregularities of the Teeth and their Correction, vol 1. New
York, NY: DeVinne Press, p. 658. Saito S, Ngan P, Saito M, et al. (1990a) Effects of cytokines on prostaglan-
din E and cAMP levels in human periodontal ligament fibroblasts in
Ghafari JG (1997) Emerging paradigms in orthodontics – an essay. vitro. Archives of Oral Biology 35: 387–95.
American Journal of Orthodontics and Dentofacial Orthopedics 111:
573–80. Saito S, Ngan P, Saito M, et al. (1990b) Interactive effects between cytokines
on PGE production by human periodontal ligament fibroblasts in vitro.
Ikawa M, Fujiwara M, Horiuchi H, et al. (2001) The effect of short-term Journal of Dental Research 69: 1456–62.
tooth intrusion on human pulpal blood flow measured by laser Doppler
flowmetry. Archives of Oral Biology 46: 781–7. Sandstedt C (1904) Einige beiträge zur theorie der zahnregulierung. Nord
Tandlaeg Tidskr 5: 236–56.
Ketcham AH (1929) A progress report of an investigation of apical root
resorption of vital permanent teeth.International Journal of Orthodontics, Wilcko MT, Wilcko WM, Pulver JJ, et al. (2009) Accelerated osteogenic
Oral Surgery and Radiology 15: 310–28. orthodontics technique: a 1-stage surgically facilitated rapid orthodon-
tic technique with alveolar augmentation. Journal of Oral and
Kiyak HA (2008) Does orthodontic treatment affect patients’ quality of Maxillofacial Surgery 67: 2149–59.
life? Journal of Dental Education 72: 886–94.

2

Effective Data Management and Communication
for the Contemporary Orthodontist

Ameet V Revankar

Summary computer is a positive step, it is not enough. A continuity-
of-care record is needed in order to document, measure,
In this modern competitive era, technology offers all of us modalities we support and coordinate within and between specialties. The
can use to stand above the rest. Health information technology has the challenges in this task include the threat of information
potential to greatly improve healthcare alongside yielding huge savings. overload, the need to provide for data-sharing between spe-
Over the past several decades, computer systems and information tech- cialists, the appropriate use of the data for the delivery of
nology have pervaded all aspects of dentistry, successfully bridging the healthcare, and prevent misuse and loss of data. All of these
divide between the clinical setting and research. However, this trans- challenges need to be considered before installation of
formative technology demands learning of new skills to understand, health information technology (Boyd et al., 2010).
maintain and use it effectively, and to deliver what it promises to deliver.
The role of communication processes, verbal/nonverbal, oral/written, in Effective communication is defined as the exchange of
human interactions needs no emphasis, as it forms the core basis of all information and a person’s beliefs to provide feedback and
successful relationships across humanity beyond creed, race, and ethnic- communicate one’s message. When translated to the
ity. One such relationship is the doctor–patient relationship, which is doctor–patient scenario, communication entails the ability
constantly evolving. Having moved from paternalistic to ‘equal partners’, of the doctor to comprehend fully the patient’s concern and
it is now more likely progressing towards a ‘service provider–consumer’ medical information, diagnose the problem, and advocate
format. Moreover, in the new ‘cyber age’ reliance on electronic commu- a treatment plan, to the satisfaction of both parties. In this
nication is constantly on the rise, far superseding interpersonal contacts. communication process, the doctor and the patient assume
This chapter discusses the integration of information technology systems the roles of the communicator and the receiver, alternately,
in orthodontics, to improve work flow and efficiency, as well as for the until a common consensus is arrived at. The ultimate goal
management and protection of electronic data from theft and corruption. of an effective communication process is to foster a strong
It also discusses the various methods of electronic communication in doctor–patient relationship, linked to important outcomes
patient management per se, as well as electronic communication with of care–treatment compliance (Francis et al., 1969;
other specialists and peers, and its increasing role in orthodontic DiMatteo, 1995), clinical outcomes (Greenfield et al., 1988;
education. Kaplan et al., 1989), malpractice claims (Beckman
et al., 1994), and transfer of patients between doctors
Introduction (Marquis et al., 1983). Evidence indicates that good doctor–
patient relationships are on the decline, due to consumer-
Information technology refers to the use of computers and centric attitudes, decrease in professionalism, and
software to produce, manipulate, store, communicate, and/ commercialization of healthcare delivery systems (Chaitin
or disseminate information. Computerized data manage- et al., 2003). The path to a better doctor–patient relation-
ment systems are becoming an integral part of any health- ship demands better communication, aimed at the patient’s
care system and transforming it through integration of all perspective of treatment and includes the patient as a col-
clinical disciplines. Although encoding clinical data into a laborative partner with his or her doctor (Roter, 2000;

Integrated Clinical Orthodontics, First Edition. Edited by Vinod Krishnan, Ze’ev Davidovitch.
© 2012 Blackwell Publishing Ltd. Published 2012 by Blackwell Publishing Ltd.

16  Integrated Clinical Orthodontics

Murphy et al., 2001), beginning with scheduling the through an interactive voice-based system (IVRS), which
patient’s initial visit, progressing through diagnostic can be phone based or integrated into the office website
records, scheduling diagnosis, treatment planning, finances, (web based). The web module IVRS may be integrated
finally culminating in the execution of the treatment plan. into a single program that is also amenable to manual
All the aforementioned tasks are aided by use of software entries by the office staff. Such administrative applications
programs that can enhance the doctor–patient experience, deployed over the internet, enable patients to interact with
taking it to previously inconceivable heights. the organizational aspects of the orthodontic practice.
Online appointment scheduling, pre-registration, pre-visit
The role of information technology in preparations, and out-of-pocket treatment cost estimates
the orthodontic practice all enhance communication and convenience. By having
more control and a sense of participation in the adminis-
Practice management systems trative processes of the orthodontic office, patients may
develop greater trust in the practice as a whole and poten-
Practice management software (PMS) is a computer tially a better relationship with the doctor (Anderson et al.,
program/s that performs and organizes the administrative 2003).
and clinical areas of an orthodontic practice. Traditionally
PMS was limited to administrative tasks, and the electronic Payment/financial record maintenance
medical record (EMR) system was meant for maintaining
patient medical records. However, the current versions of It is paramount to document financial details for each
PMS available for orthodontic use have integrated EMRs appointment, to ensure transparency and ease of insurance
and track appointments, billing, clinical information, and claims, if applicable. Each charge usually corresponds to a
aids in patient communication, helping orthodontists to particular service performed during a particular appoint-
manage everyday tasks more efficiently than ever. A PMS ment, and most of the time multiple treatment procedures
also tracks referrals with generation of new referral reports, are performed by the operator. The settlement of the insur-
while managing incoming referrals from other specialists. ance claim, if applicable, may be performed as an auto-
mated process by the software, using proprietary electronic
Patient demographic documentation by data interchange with the insurance company’s server. This
the assistant process is termed electronic claims submission (ECS).
Electronic fund transfer (EFT) is the process whereby
Patient demographic documentation often starts when a patients can pay a fee by electronic means, such as credit/
new patient fills out a detailed information chart, which debit card. Online banking can be automatically drafted by
includes the patient’s name, address, contact information, the software, enabling automatic debit from the payer’s
birth date, employer, and insurance information. Office account, and deposit it into the practice’s account on due
staff manually enter this information into the software. The dates (Lewis, 2006). The aforementioned steps of appoint-
software can automatically interact with the relevant insur- ment scheduling, capturing patient demographics, and per-
ance company server in real time when connected over the forming billing tasks are usually integrated into one module
internet, to verify the patient’s credentials. – the PMS (Table 2.1).

Scheduling patient visits Advantages of using PMS

Patient appointment scheduling programs, the most A PMS:
important among administrative tasks, should consider
proper management of the practitioner’s time, cost- • Enables easy identification of new patients and round-
effectiveness, flexibility, which can reduce overheads and the-clock appointment scheduling
increase patient satisfaction. Various software programs
are available for scheduling patient visits – integrated

Table 2.1  Comparison of patient management software systems

Software Website Special features

Dentimax www.dentimax.com/ IVRS, e-module
SaralDent Dental www.saralindia.com/ Manual SMS and email reminders
Medipac Dental www.e2ilabs.com/ Automated SMS and email reminders
Curve Hero www.curvedental.com/ Web-based interface; anytime/anywhere access

All are shareware. Free demo copies can be downloaded from the company websites.
IVRS, interactive voice-based system.

Effective Data Management and Communication for the Contemporary Orthodontist  17 

• Enhances ability to manage multiple appointment • EPRs are recorded/stored in the ASP server and thus
schedules available from any geographical location in the internet-

• Helps locate patient records easily by name or date • connected world
• Makes easy the process of call-backs, rescheduling, and The patient data access system is easily integrated on the
• referring of patients to different offices office website, providing patients, insurance agencies,

Minimizes recalls, missed and overlapping • and referring doctors with easy access
Customer support is rapid in case of the unforeseen
• appointments event, because the servers are offsite, in the custody of
Makes possible cross-scheduling among multiple clinics the ASP provider.

• and medical offices Although safety of patient data is of major concern as
Reduces staffing and administrative overhead, thus the data is stored on ‘out of office’ servers, these ASP servers
are managed by professionals, and are compliant with
• enhancing revenue privacy norms and data protection policies.
Has built-in reports that help save time and reduce paper
Computer-aided diagnosis and treatment
• clutter planning to enhance communication
Prompts sending reminder letters/phone calls/SMS to
patients in what are known as patient communication Case documentation
systems
The majority of available software for orthodontic offices
• Reduces stress for the patients and staff includes case documentation modules for routine dental
• Eliminates the need to physically transfer patient infor- complaints, and special modules for all dental specialties
• mation from one place to another (Figure 2.1). These programs allow the practitioner to make
accurate diagnoses and create compelling treatment plans.
Enables transparency in financial transactions with the Some software vendors offer case sheet customization
use of EFT and ECS. based on the practitioner’s needs. The integrated functions
and features enable the practitioner to present recommen-
Although an electronic patient record (EPR) offers dations to patients in a way that they can understand,
several advantages over conventional paper records, it making communication easier.
suffers the risk of tampering. Attorney Arthur Pearson
points out that in case of litigation, the prosecution could Diagnostic record taking
easily argue that the patient’s electronic record has been
tampered with, and this would put the defendant in an Digital photographs
indefensible position (Scholz, 1989). Methods to overcome Digital photography has replaced film-based cameras due
this issue include creating monthly duplicates of datasets, to its unparalleled advantages in routine clinical practice
which are placed in an offsite data server ‘escrow’, or having over conventional film images, for example immediate
printed records, as well. The former option is expensive visualization of the captured image, possibility of image
and, the latter defeats the very purpose of having a ‘paper- enhancement, indefinite ‘shelf life’ of the ‘soft copy’, ease of
less’ electronic record. Current PMS/EMR program data- printing and duplication, absence of film, processing costs,
bases have features discouraging/preventing tampering. and ease of electronic transmission around the world
They usually require two digital signatures for every entry (Sandler et al., 2002; Revankar et al., 2009a). Further, the
completed. Any changes/additional entries are added as a immediate availability of images enables the doctor to dem-
separate addendum entry. Tampering is quite an arduous onstrate the current status of the patient’s dentition and
task, even for experienced programmers. In the unlikely extraoral features to them. Digital photography experience
event that data have been tampered with, the electronic trail has been enhanced by availability of programs that can
is traceable in case of litigation (Starke and Starke, 2006). perform wireless transfer of photographs from the camera
to the computer (Revankar et al., 2010), ability to auto­
The deployment of PMS or other solutions for a ‘paper- matically tag photographs with DICOM (digital imaging
less office’ requires the setting up of a local area network and communication in medicine)-compatible data, auto-
(LAN) with a server and client system architecture (Haeger, matic parsing of duplicate photographs, and colour/hue
2005). Alternatives include internet program delivery matching (Halazonetis, 2004). It is now possible to inte-
(IPD)- or application service provider (ASP)-based solu- grate cone-beam computed tomography (CBCT) data in
tions, which are basically outsourced hosting and delivery DICOM format with standard extraoral frontal photo-
of management software, including data backup and graphs of the patient to generate three-dimensional (3D)
archiving, and therefore do not require extensive hardware facial photographs without the need for 3D facial camera
setup in the office.

Advantages of ASP solutions over office installed/
maintained programs include (Lewis, 2006):

• No need to enforce local data management and protec-
tion systems

18  Integrated Clinical Orthodontics

Figure 2.1  Example of an orthodontic case documentation module.

systems (Mah, 2007). This is sometimes referred to as 2D systems’ and capable of generating 3D models. The first
facial photo wrap (Dolphin Imaging and Management dedicated impression scanning system in orthodontics is
Solutions, Chatsworth, CA) (Figure 2.2) and is definitely a the Orascanner (Suresmile, OraMatrix, Richardson, Texas,
giant step ahead in rendering a visual identity to the USA), a light-based imaging device that projects a precisely
patient’s 3D volume. patterned grid onto the teeth. The orthodontist can make
a diagnosis and plan treatment on the computer, using
E-models software tools to measure tooth and arch dimensions (Mah
The transition from physical study models to 3D images is and Sachdeva, 2001). The virtual models also act as a valu-
progressing slowly due to the expensive nature of the 3D able tool for patient education (Figure 2.4).
model scanners. Desktop-based model scanners are avail-
able both in the LASER (light amplification by stimulated Digital radiography
emission of radiation) and optical/white structured light Radiographic imaging has now progressed from 2D to 3D
variety (Table 2.2). However, outsourcing options are avail- with the increasing use of CBCT. 3D CBCT scans are also
able, whereby the physical models or impressions can be being used as alternatives to standard plaster models (Figure
sent to the 3D modeling company and the 3D models gen- 2.5) and 3D-based dental measurement (3DD) programs
erated from it are downloaded through the internet (Table (El-Zanaty et al., 2010). The advantages of 3D CBCT
2.3). The orthodontist has to log on to the company website models over conventional plaster and other forms of digital
with his or her unique case ID enabling round-the-clock models are (Chenin et al., 2009):
access to the digital models (Figure 2.3). These 3D models
have proved to be viable alternatives to plaster models, in • Include not only the tooth crown, but also the roots
terms of measurements, diagnosis of malocclusion, and • Impactions/developing teeth and alveolar bone can be
treatment planning (Tomassetti et al., 2001; Stevens et al., • visualized
2006).
Dynamic virtual setup simulation and generation of
An alternative to standard impression techniques is stereolithographic models using computer-aided manu-
intraoral scanning, termed ‘dedicated impression scanning facturing (CAM) is possible.

Effective Data Management and Communication for the Contemporary Orthodontist  19 

Figure 2.2  2D facial wrap. (a) 3D craniofacial skeleton rendering from cone-beam computed tomography data. (b) Standard 2D digital photograph of the
patient. (c) Facial photo wrap. (Image courtesy of Dolphin Imaging and Management Solutions, Chatsworth, CA; www.dolphinimaging.com.)

Table 2.2  Commercially available desktop model scanners

Name of the scanner Type of scanner Output format Website

3Shape R700 Orthodontic 3D scanner LASER STL, DICOM www.cadbluedental.com
Maestro 3D dental scanner Structured light STL, PLY, OBJ, ASC, VRML www.maestro3d.com
ShapeGrabber Ai210D 3D dental scanner LASER STL www.dentalscanner.com

STL, stereolithography; ASC, Autodesk, Inc 3D file; DICOM, digital imaging and communications in medicine; OBJ, wavefront technologies format; PLY, polygon
file format; VRML, virtual reality modeling language.

Table 2.3  Commercial outsourcing-based digital modeling and archiving solutions

Solution Company Website

Orthocad Cadent, Carlstadt, NJ, USA www.cadentinc.com
e-model GeoDigm, Chanhassen, MI, USA www.geodigmcorp.com
Orthoplex Dentsply GAC International Bohemia, NY, USA www.gacintl.com/orthoplex
Ortholoine Objet Geometries Inc Billerica, MA, USA www.objet.com/Pages/Case_Studies/Medical/Ortholine
Anadent 3D Sinthanayothin C, Thailand www.anadent3d.com
Orthomodel Tarcan B, Istanbul, Turkey www.orthomodel.com/eng

20  Integrated Clinical Orthodontics

(a) Color-coding of the
contact surface
2D projection for varies according to
overjet/overbite the strength of the
measurement contact

Overjet/overbite Create dental base
function control

3D space shows cutting plane for Overjet/overbite checking

(b)

Figure 2.3  (a) Flow chart for outsourcing plaster model digitization. (Courtesy of Dr Roopak D. Naik, Dharwad, India.) Clockwise from left – the doctor ships
the rubber base impressions or plaster casts to the 3D model company and 3D scanning is accomplished in the company’s scanner. Following this the digital
models are available on the company’s secure login webpage where the doctor logs in to see the models or download them. (b) Visualization and manipulation
of digital models in Anadent 3D software. (Image courtesy Dr Sinthanayothin C, NECETC, Thailand.)

Effective Data Management and Communication for the Contemporary Orthodontist  21 

(a) purchase and instalation of software (Table 2.4). Either
digital or film radiographs, scanned or photographed on a
(b) viewer, can be used with a scale adjacent to the film that
enables software calibration. At the time of writing, digiti-
(c) zation of the film prior to automatic analysis is on the brink
Figure 2.4  (a) The Orascanner apparatus. (b) Intraoral scanning with the of change from manual to automatic landmark identifica-
Orascanner. (c) 3D digital model generated from the scan. (Image courtesy Dr tion, using the ‘neural-associative-processor-based’ hard-
Rohit Sachdeva, OraMetrix, Inc., Richardson, TX.) ware recognition systems (Yagi and Shibata, 2003). These
Two-dimensional cephalometry systems have been demonstrated successfully to identify
landmarks automatically, with high accuracy without
There have been tremendous advancements in the field of human input in both adults and adolescents (Tanikawa
lateral cephalometric radiograph digitization, tracing, anal- et al., 2010).
yses, and treatment prediction, and a horde of cephalom-
etric software is available for this mundane task. Online Three-dimensional cephalometry
cephalometric analysis alternatives (Abraham, 2007) are Since the inception of the cephalostat, Broadbent tried
also available (per case charge) that do not require the advocating a 3D stereoscopic analysis, and suggested com-
bined use of the lateral cephalogram, postero-anterior
radiograph, and a submental vertex view (Broadbent, 1931).
However, the essence of Broadbent’s cephalostat was lost
over the decades, when orthodontists worldwide used the
lateral cephalogram, which is a 2D representation of a 3D
object, as the primary diagnostic head film with its inherent
disadvantages. As pointed out earlier, 3D cephalometry
with the newer CBCT machines is as close as it can get to
craniometry in the intact human (Gribel et al., 2011a,b).
The biggest problem with 3D cephalometry is the absence
of population norms for the 3D measurements, and this
was recently addressed by Gribel et al. (2011a,b). Assessment
of changes due to growth or treatment as well as evaluation
of internal structures can be done using 3D volumetric
superimposition technology (Dolphin 3D, Dolphin Imaging
and Management Solutions, Chatsworth, California, USA).

Discussing treatment with the patient

A motivated patient who understands and undertakes
responsibility for his or her treatment is an asset to any
practitioner. To inspire treatment compliance, a patient
needs to understand the treatment procedure he or she
might undergo, which is graphically possible with the aid
of interactive motivational software (Table 2.5). The graph-
ical simulation of a treatment procedure to be undertaken
can aid eliciting truly informed consent (Figure 2.7).
Commensurate with the fact that the human brain registers
and recalls more of what is seen in comparison with inputs
received through the other senses, there is evidence suggest-
ing that these computer-based visual patient education
programs enable better recall and hence positive feedback
from the patient, in comparison with traditional means of
patient education alone (Patel et al., 2008). Post-treatment,
predicted profiles of the patient can also help in this
endeavor. In fact, it is mandatory in some countries to show
the software-generated post-treatment composites of varied
treatment options to the patient before treatment (Figure
2.8). Previously, only 2D profile predictions were possible.
However, with ‘dynamic CBCT’ technology it is now

22  Integrated Clinical Orthodontics

(a) (b)

Figure 2.5  Dental models generated from CBCT data. (a) Models on bases trimmed to ABO standards. (b) Occlusal views. (These digital models were generated
with Anatomodel software. Anatomage Inc., San Jose CA www.anatomage.com; reproduced with permission from German and German, JCO April 2010).

Table 2.4  Comparison of various 2D and 3D cephalometric software

Software Website Special features

Viewbox www.dhal.com 3D module for CBCT data
Onyxceph http://2i.webworld.org/ Model analysis from photographs
Ceph Basic www.image-instruments.de/ceph-basic/en/index_us.htm Includes patient education module
Dolphin Imaging www.dolphinimaging.com 3D module for CBCT data
Vistadent www.gactechnocenter.com/V3D.htm 3D module for CBCT data
Anatomage 3D www.anatomage.com Automatic digitization
Cephanalysis.com www.cephanalysis.com Outsourcing; per case

CBCT, cone-beam computed tomography.

possible to generate 3D composites of predicted treatment yore. The internet has made communicating between geo-
outcomes (Figure 2.9). graphically distant locations and time zones incredibly easy.
In orthodontics, this means easy and reliable dissemination
Other arenas of communication of information, electronic patient communication and
appointment scheduling, patient referral to colleagues,
Communication using the internet transfer of patient records, online diagnostic aids, backup
The internet is probably the biggest invention of the mil- and retrieval, journal manuscript submissions, distant
lennium and among mankind’s best, comparable with the learning through webinars, real time interaction without
invention of the integer zero by Indian mathe­maticians of physical presence of faculty, and much more (Engilman

Effective Data Management and Communication for the Contemporary Orthodontist  23 

(a) (b)
Figure 2.6  Pre- and post-3D volumetric superimpositions of mandibular advancement surgery. (a) Hard tissue superimposition: blue is post surgical. (b) Soft
tissue superimposition. (Image courtesy of Dolphin Imaging and Management Solutions, Chatsworth, CA; www.dolphinimaging.com.)

Figure 2.7  Screenshot from a patient education software.

Table 2.5  Patient education software et al., 2007). Modes of communic­ ation using the inter-

Software Website net include (Revankar and Gandedkar, 2010):

Caesy www.caesy.com/ • Email (electronic mail)
Optio www.optiopublishing.com/ • File transfer protocol (FTP)
Orasphere www.orasphere.com/ • Hyper text transfer protocol (HTTP) file transfer
Consult Pro www.consult-pro.com/ • RFB (remote frame buffer) protocol and VNC (virtual
Dolphin Aquarium www.dolphinimaging.com network computing)
Orthomation www.gactechnocenter.com
• VoIP (voice over internet protocol)
• Video teleconferencing/videoconferencing (tele-

orthodontics) (Figure 2.10).

Figure 2.8 Predicted post-treatment profiles for
varied treatment plans in an orthognathic patient,
generated with Dolphin Imaging 10. (Image cour-
tesy of Dolphin Imaging and Management Solu­
tions, Chatsworth, CA; www.dolphinimaging.com.)

(a)

Figure 2.9  3D soft tissue prediction of orthog-
nathic surgery. (a) Mandibular osteotomy on cone-
beam computed tomography (CBCT) dataset – right
view. (b) Mandibular osteotomy on CBCT dataset
– 45° view. (Image courtesy of Dolphin Imaging
and Management Solutions, Chatsworth, CA;
(b) www.dolphinimaging.com.)

Effective Data Management and Communication for the Contemporary Orthodontist  25 

Figure 2.10  Schematic representation showing the various methods of data transmission over the internet and their associated protocols.

Figure 2.11  Email transmission and the underlying protocol. Email servers/ time on confirming appointments using phone calls, effec-
MTAs/MDAs use SMTP to send and receive email messages; user-level client tively reducing the ‘number of no shows’ (Povolny, 2002).
mail applications typically only use SMTP for sending messages to a mail Dedicated online patient communication (OPC) programs
server for relaying to other MUAs. For receiving messages, MUAs usually use are available and automate the emailing chore; they can
either POP or IMAP to access their mail box accounts on a mail server follow- integrate with the office PMS, extracting data pertaining to
ing authentication. MUA, mail user agent; MTA, mail transfer agent; SMTP, payments, insurance claims, and appointment schedules
simple mail transfer protocol; MDA, mail delivery agent; IMAP, internet (Ortho Sesame software, PT Interactive Tukwila, Wash;
message access protocol; POP, post office protocol. TeleVox Software, Mobile, Ala; www.televox.com). These
OPC suites can be integrated onto the office website, ena-
Email bling patients to enter their email addresses in the database
Email has become the standard form of mail, with land mail as well as access their information online from the office
being dubbed as ‘snail mail’ in this fast-paced world. Instant website as described below. However, some clinicians are of
data transmission is now a necessity in every field, includ- the opinion that email communication has a negative
ing orthodontics. The internet serves as an effective plat- impact on doctor–patient relations because of the lack of
form, transcending all dimensions – space, time, and matter the nonverbal component (body language) that is vital to a
– for exchanging information with patients, peers, consult- successful interpersonal contact (Baur, 2000).
ants, manuscript transactions, leisure, etc., to name a few.
The amount of content a typical email can hold ranges File transfer protocol
from 10 megabytes (MB) to a maximum of 20 MB, depend- FTP allows transmission of much larger files. The process
ing on the service provider. Simple mail transfer protocol typically involves the acquisition of an ‘user account’ on an
(SMTP) is the current internet standard for email transmis- FTP server, either free or paid, following which the user
sion across internet protocol (IP) networks (Figure 2.11). uploads files onto the server. Once a file is uploaded, it
is available for download worldwide, provided the
Email communication pertaining to appointment downloader has the user account details for the uploaded
reminders, payment receipts and birthday/festival wishes file. Some FTP servers such as Drive HQ (www.drivehq.com/
enhance the doctor–patient relationship (Anderson et al., FTP) provide 1 gigabyte (GB) of free space and upload
2003) by providing the patient with a ‘sense of importance’. of a maximum file size of 100 MB/file for free users. FTP
Email appointment reminders can save the reception staff was a popular protocol a decade ago but is no longer
in vogue today, except for special applications such as
webpage/content uploads for uploading content on the
office website.

Hyper text transfer protocol file transfer
HTTP is similar to FTP, the difference being that this pro-
tocol is browser based (Internet Explorer/Mozilla Firefox)
and runs on the World Wide Web platform, the predominant

26  Integrated Clinical Orthodontics

Table 2.6  Comparison of various HTTP file servers

HTTP file server Maximum file sizea allowed Passworda file protection Searchable data base

www.rapidshare.com 200 MB/file unlimited storage No No
www.mediafire.com 100 MB/file unlimited storage Yes Yes
www.adrive.com Up to 50 GB both file size and storage No Yes
www.sendthisfile.com 100 MB/file Yes No

aFor free users. Generally subscription services allow uploading of large files of ranging from 2 GB/file to 10 GB/file depending upon the file server.

platform on the ‘WEB’ as of this date, because of its user- Voice over internet protocol
friendliness and graphical user interface. Many websites VoIP or IP telephony as it is popularly known, is based on
provide simple-to-use data upload service, both free and a simple method of converting analog signals (for instance
paid. The user can choose to password protect a file or keep sound waves) into digital packets before being transmitted
it open to access. Once uploaded, the file is available for over the internet. Soft phones (VoIP software running on
download all over the internet, any number of times, and a computer) are free to use for computer-to-computer
can serve multiple downloads at the same instance as well. calling anywhere in the internet-connected world. They can
The standard procedure requires the uploader to distribute also be used to call conventional phones (landlines and cell
the link to download the file via email, message boards, phones) at nominal prices. Other endpoints for using the
websites or any other form of communication. Some file VoIP protocol may be the analog telephone adapter (ATA)
servers allow the user to place their file in a searchable and IP phones (Mupparapu, 2008). These phones do not
database (Table 2.6). Large file transfers up to 2 terabytes require an intervening computer to process the voice call
(TB)/session are now feasible, thus making the transfer of and can be used like standard public switched telephone
large patient image files/radiographs, procedure videos, and network land phones. Wi-Fi phones that use VoIP when
lectures possible. Most manuscript submission systems for located in a Wi-Fi hotspot are also available. Applications
international orthodontic journals also follow this protocol such as Fring (www.fring.com) enable Symbian/Windows
for electronic manuscript submission. smart cell phones to do the same, when connected to a
Wi-Fi network, enabling cross platform connectivity with
Remote frame buffer protocol other VoIP and instant messaging clients. This technology
RFB protocol enables remote access to graphical interfaces. can be used for cheap voice calling in comparison with the
Along with virtual network computing (VNC), it forms the traditional telephone system, especially when call volumes
heart of applications such as TeamViewer and Dynagate are high and office overheads are to be kept low (Mupparapu,
(TeamViewerGmbH, Göppingen, Germany), which enables 2008).
real-time file transfer. TeamViewer establishes true virtual
private network (VPN)-encrypted connection, enabling Video teleconferencing/video conferencing
direct high-speed file transmission from one user end to This is a set of interactive telecommunication technologies
the other (point to point) without an intervening file server. that allow two or more locations to interact via two-way
Files can also be transferred through popular instant mes- video and audio transmissions simultaneously. The sim-
saging clients, such as Yahoo messenger, Google Talk, and plest video conferencing system – point to point – and
Skype, using the same protocol. These applications can be suitable for individual use at home or private orthodontic
used for real-time textual ‘chat’ between practitioners, office, consists of inexpensive equipment, namely a PC, a
student/faculty instructions, and online patient support via web camera, software and a high-speed internet connection
‘chat rooms’ embedded on the office website. Offsite infor- (Engilman et al., 2007). This technology is shaping the
mation systems management, which involves ‘out-of-office’ future, enabling interaction among colleagues, for case dis-
management of ‘in-office computer systems’ that is operat- cussions – interactive seminar instruction in orthodontic
ing any computer system on an internet-connected network residency programs (Bednar et al., 2007; Engilman et al.,
as though the remote operator is physically present on the 2007; Miller et al., 2007).
local computer, is possible with applications such as
TeamViewer. ‘Chat room’ discussions for interactive learn- Traditional computer-assisted learning (CAL), the
ing have been implemented, but have not been very suc- multimedia approach to learning, is a form of self-
cessful, probably because this form of education is not instruction in which material can be presented via text,
‘taken seriously’ unless accompanied by a video feed visual, sound, and motion digital files (Rosenberg et al.,
(Proffit, 2005). 2005). CAL is not a novel method of learning, having been

Effective Data Management and Communication for the Contemporary Orthodontist  27 

in existence for as long as computers have been around. difficulties in installing multiple tracking cameras and
It is a necessary tool in the current educational system locating microphones to ensure voice clarity throughout
(Rosenberg et al., 2010) and offers several advantages
(Rosenberg et al., 2003). • the room.
There are inherent problems with the reliability of the
• It motivates and generates interest in the student towards
• the subject. • high-speed internet connections.
Supplemental electronic teaching materials are not
Students can learn at their own pace and review the inbuilt within the system and need to be distributed by
other means before the session.
• lesson any number of times.
Students can access the system in a convenient, Web conferencing also forms the basis of futuristic tele-
orthodontics. Telemedicine currently offers real-time ‘live’
• distraction-free environment. and ‘store and forward’ videoconferencing and consulta-
Multimedia and interactive animations can enhance self- tions (Miller, 2003). At present, tele-orthodontics is the
delivery of some aspect of orthodontic care where the
• communication and understanding. patient and doctor are geographically separated. According
They can reduce the need for educators. to Favero et al. (2009) minor orthodontic emergencies can
be resolved easily at home, reassuring patient and parents,
Meta-analyses have found that CAL increased student and limiting visits to the orthodontic office to cases of real
examination scores by 0.3 standard deviations, decreased need.
instructor-based learning schedules (Kulik and Kulik, 1991),
and led to a small to moderate improvement in student Internet-based applications will neither replace ‘hands-
scholastic achievement (Dacanay and Cohen, 1992). on’ care and treatment from the doctor, nor the social
Controlled trials in orthodontics, comparing CAL with quality of a personal interview. However, this new technol-
conventional teaching methods, are split between no differ- ogy is affecting the quantity and quality of health informa-
ence (Clark et al., 1997), significant advantage of CAL tion that patients can obtain, the number of aspects of care
over conventional teaching (Luffingham, 1984; Irvine being provided, and the nature of the doctor–patient rela-
and Moore, 1986; Al-Jewair et al., 2009), and significant tionship (Hollander and Lanier, 2001). The World Wide
advantage of conventional methods over CAL (Hobson Web is a sea of knowledge, full of readily available informa-
et al., 1998). Current evidence suggests that CAL is defi- tion. Many patients confront their doctor with information
nitely useful as an adjunct to conventional teaching but they have gleaned from the internet. Some doctors are
cannot be used as the only teaching modality (Rosenberg alarmed by this, while others embrace the role of the inter-
et al., 2010). net with their patients and provide health information and
links to preferred sources of health information on their
Web conferencing own websites. It is the responsibility of the doctor to guide
This is a conglomeration of various protocols delivering the patients toward credible resources because knowledge
simultaneous multicast video, audio conferencing, real- resources on the internet are a mixed bag with variable
time file transfer, and screen sharing, used to conduct live contents, quality, and readability (Antonarakis and
meetings, training, or presentations via the internet. In a Kiliaridis, 2009). With level access to information about the
web conference, each participant sits at his or her own full range of treatment options, patients are actively partici-
computer and is connected to other participants via the pating in deciding on a course of treatment and other
internet. This arrangement can be either a downloaded aspects of their healthcare.
application on each attendee’s computer or a web-based
application, where all attendees access the meeting by click- Evidence on the internet
ing on a link distributed by email (meeting invitation) to
enter the conference. The internet is a great resource for readily accessible evi-
dence. Various scientific literature databases such as
Multicenter web conferencing, with high-speed internet PubMed, MEDLINE, Cochrane, EMBASE, DARE, ERIC,
networks, forms the back bone of high-quality interactive, and Google scholar, can be searched for pertinent informa-
long-distance seminar instructions (Bednar et al., 2007). tion. In 2006, the Council on Scientific Affairs (COSA), a
The convergence of two major forces – evolving techno­ division of the American Association of Orthodontists
logy and orthodontic educator shortage – is leading to (AAO), developed a website for evidence-based orthodon-
further development of virtual classrooms for interactive tic literature, linked to the AAO members’ area. The data
learning (Scholz, 2005). However, technology is still evolv- on pertinent topics listed on these ‘organization endorsed’
ing and some disadvantages exist in interactive web websites should be held with high regard as it usually
conferencing. presents chimeric data synthesized from the best available
evidence.
• Active participation of each and every participant cannot
be ensured, especially so in a large group because of the

28  Integrated Clinical Orthodontics

The office website content, photographs, and videos for the office website
The internet is a significant consumer research resource cannot be underplayed. The website should be an interac-
center in the current era. Hence, building up a practice tive hub where patients, both old and new, can find answers
website, and maintaining and making web presence notice- to their questions. New patient registration can be done
able are critical. Web presence can be enhanced by search through the website, as mentioned earlier. Further, a health
engine optimization and pay per click advertisements history form can be provided online so that the prospective
on other popular websites using Google Ads. Even broad- patient can fill in the necessary details before arriving at the
casting yourself through the popular social networking office. Patients already into treatment can be provided with
websites – Facebook (www.facebook.com), Orkut (www. secure access to their own personal orthodontic health
orkut.com), Twitter (www.twitter.com) and YouTube record through the website.
(www.youtube.com) – to expand your reach is now
possible. Electronic data management

Apart from advertising, the office website is an important From the preliminary step of patient communication, diag-
cornerstone for a successful doctor–patient relationship. nostic record making, and treatment planning, to the future
Being the face of the doctor’s practice, the website typically follow-up regimen, digital technology delivers unparalleled
includes information about the doctor, office staff, equip- and unique services to orthodontics. With the advent of this
ment, office policies, and values. A prospective patient can technology, orthodontists around the globe have embraced
relate these values to him or herself. This ‘initial communi- the ‘techno-wave’ in various forms. Data storage has also
cation’ may lay the groundwork for a good doctor–patient seen a change from paper to disk drives and photographic
relationship by providing a sense of trust and shared values. film to flash cards. Changes in the method of storage, have
There is evidence to prove that incorporation of certain led to new challenges in data protection, from termites to
design characteristics and content on the office website are computer viruses (Revankar et al., 2009b). The Wikipedia
important for attracting prospective new patients. The fol- online encyclopedia defines computer malware, also called
lowing content is deemed to be critical to attract new malicious software, as ‘software designed to infiltrate or
patients (Wallin, 2009): damage a computer system without the owner’s informed
consent’ (Malware, 2010). The expression is a general term
• Doctor’s photograph – a color photo in ‘usual clothing’ used by computer professionals to refer to a variety of
with a child or their family forms of hostile, intrusive, or annoying software or program
codes, which can often be destructive, if appropriate and
• Patient-focused content throughout the website timely action is not undertaken.
• Warm doctor’s statement – demonstrating care and
• concern for patients Most people are unaware of the term malware and use
the term computer virus incorrectly to describe all sorts of
Doctor’s credentials and experience listing, including malware, as not all malware are viruses but all viruses are
information about continuing education, to show that malware. The legal codes of several American states, includ-
the doctor is abreast with the latest technologies and ing California and West Virginia refer to malware as a
computer contaminant (National Conference of State
• techniques Legislatures, 2008). Of late, the majority of computer code
Individual staff photographs, with information about being released is malicious. Preliminary results from
each staff member, showing their friendliness towards Symantec (Symantec Internet Security Threat Report,
2007) sensors published in 2008, suggested that ‘the release
• patients rate of malicious code and other unwanted programs may
First visit page – a compelling page as to why patients be far exceeding that of legitimate software applications’.
should choose this particular practice, what happens at According to F-Secure, ‘As much malware was produced in
2007 as in the previous 20 years altogether’ (F-Secure
• the first visit and consultation fees Corporation, 2007) Malware’s most common pathway
Happy people’s photographs – emotionally impactful from criminals to users is through the internet, by email
smiling faces (which look as if they could be faces of and the World Wide Web. In a setup like a dental office,
malware can spread rapidly to even standalone systems
• patients) throughout the website through the pervasive use of thumb/flash drives for data
Warm and friendly design theme without pop-ups, transfer.

• splash pages, and auto music or advertisements. Protection against malware
Before and after treatment page – with three to six com-
pelling, full-face photographs of the doctor’s patients. Most systems contain bugs (vulnerabilities), which may
be exploited by malware. Typical examples are buffer over-
When consulting a professional agency to design a
website for your office, remember that most of them churn
out ‘template-based’ websites, which ultimately result in all
‘orthodontic office websites’ designed by the same agency
looking similar to each other (Turpin, 2008). Creating indi-
viduality for your practice is very important; hence the
doctor’s inputs to the web designer on the design, textual

Effective Data Management and Communication for the Contemporary Orthodontist  29 

runs, in which an interface designed to store data in a small always use Google to find more testers. However, these
area of memory allows the caller to supply too much, and testers are effective only if they are frequently updated for
then overwrites its internal structures. This function may virus signature database, given the fact that it is the malware
be used by malware to force the system to execute its code. that is written first and then the definition updates for the
Hence, the first line of defense against malware is to fix anti-malware suite. However, no battery of security soft-
the vulnerabilities in software platforms, especially in the ware can provide total immunity, which means that one can
operating system. The most effective and easiest method still get infected even though one stays updated. The best
of doing this in Microsoft’s Windows operating system is way to protect oneself in a high-risk environment such as
to turn on automatic updates. This allows the operating the World Wide Web is to reduce system vulnerability by
system to download and apply critical updates to software not using a full privileges account, such as the administrator
regularly, thus patching the loopholes as much as but to use a restricted/limited/standard user account with a
possible. software restriction policy in force.

An integrated anti-malware suite, comprising an antivi- It is of utmost importance to configure the firewall
rus, antispyware, anti-root kit and a firewall forms the to interactive mode rather than automatic mode to be
second line of defense. Availability of these integrated solu- fully aware of the established connections and to be able to
tions is widespread, but it is imperative that your security block illegitimate ones. This is quite difficult for the novice
suite does not lend false positives as much as it is important user, but can be learnt with a little practice. It is presumed
that it detects true positives. Another prime consideration here that practicing ‘safe internet behavior’, is of utmost
is that the anti-malware suite is light on system memory. importance. The top eight cyber security practices are as
There are both freeware and subscription security suites follows.
available. Independent antivirus testing websites such as AV
comparatives (Box 2.1) can guide decisions and you can • Protect your personal information – includes information
such as credit card numbers, social security number, user
Box 2.1  Products and programs for data protection and recovery names and passwords and other sensitive information.
Never store this information on your computer or
• Acronis true image, Acronis Inc., Woburn Massachusetts, USA: www. allow password remember/auto complete in the web
acronis.com/
• browser.
• AV-Comparatives, Innsbruck, Austria: www.av-comparatives.org Know who you are dealing with online – includes issues
• CCleaner, Piriform, London, England: www.ccleaner.com such as not disclosing one’s identity/sensitive informa-
• ComputerHope.com,WestJordan,Utah,USA:www.computerhope.com/ tion to strangers as well as to unsecure websites.

issues/chsafe.htm • Use a security suite with up-to-date virus definitions.
• Data Recovery Doctor, Pro Data Doctor: www.datadoctor.in • Use updated versions of operating system and browser
• ESET 5.NOD32 Antivirus for MS-DOS, ESET, San Diego, California, USA: • software.

www.eset.com Regularly back up your important files. One can use
• HijackThis, Trend Micro, Cupertino, California, USA: www.trendsecure.
• offline/online backup solutions.
com/portal/en-US/tools/security_tools/hijackthis Do not download and install software from unverified
• Ice Sword, XFocus: www.antirootkit.com/software/IceSword.htm sources. It should be noted that there are many fake free
• Knoppix, Knopper.net, Schmalenberg, Germany: www.knoppix.com anti-malware suites floating on the internet which are in
• Norton Ghost, Symantec, Cupertino, California, USA: http://us.
• fact Trojan droppers – do not fall for the bait!
norton.com/ghost Do not install pirated software, or play with cracks,
• Recover My Files, GetData Software Development Company, Hurstville, patches and keygens to convert trial software into a full
version. It is illegal as well as very risky in terms of system
New South Wales, Australia: www.recovermyfiles.com
• Stay Safe Online, National Cyber Security Alliance, Washington DC, • security.
Do not visit websites that claim to provide illegal down-
USA: www.staysafeonline.info loads of movies, software (warez), etc.
• Stinger, McAfee, Santa Clara, California, USA: http://vil.nai.com/vil/
More details on safe internet practices can be found at
stinger Stay Safe Online, a website of the National Cyber Security
• Symantec, Cupertino, California, USA: http://security.symantec.com/ Alliance (see Box 2.1).

sscv6/default.asp?langid=ie&venid=sym For more security, in the scenario of thumb/flash drive
• The Live CD List, FrozenTech, Santa Barbara, California, USA: infections, software that restricts auto-launching of all
codes from removable drives may be installed (Box 2.1).
www.livecdlist.com These software provide the required protection for stand
• Ubuntu, registered trademark of Canonical, London, UK: www. alone/non-networked computer systems in the office, from
‘wild threats’ and form the basis of the ‘prevention is better
ubuntu.com than cure’ policy.
• USB FireWall, Net Studio: www.net-studio.org/application/usb_

firewall.php
• USBAntiVirus International Inc.: www.usbantivirus.net.
• Windows CleanUp!, Steven Gould, Dallas, Texas, USA: www.

stevengould.org
• Windows, Microsoft Corporation: www.microsoft.com

30  Integrated Clinical Orthodontics

Combating a malware infection • Install and run a temporary file cleaner and standalone
malware shredders.
Despite all safety measures, a malware infection may still
occur. The steps to be followed if the inevitable happens to Reboot/restart the machine and enter the safe mode
the Microsoft Windows operating system (the most widely For entering the safe mode on most systems running
used operating system), is as follows: Microsoft Windows, hit the F8 key repeatedly when the
system is booting (Figure 2.12a,b). Additional details on
• Reboot/restart the machine and enter the safe mode entering the safe mode in all Microsoft Windows versions
• Turn off system restore can be found at Computer Hope (see Box 2.1). In this
• Do a full system anti-malware scan in safe mode (with mode, the system loads only the most critical drivers and in

updated definitions)

(a)

(b)
Figure 2.12  (a) Entering ‘safe mode’ from ‘Advanced Boot Options’ after rebooting computer. (b) The prompt to press F8 key to enter safe mode.

Effective Data Management and Communication for the Contemporary Orthodontist  31 

case one of your other drivers is infected, it can still be What are the measures to safeguard data in
disinfected. This action cannot be performed in the normal the event of a system boot failure?
mode, when these drivers may also be loaded.
The prime method to save one’s data is to always store it in
Turn off system restore a local hard disk drive partition other than that used by
In the Microsoft Windows operating environment, the your operating system. For example, you could install the
system restore feature is found under the ‘performance’ operating system in drive C, and store the data in drive D.
section of the ‘control panel’. It should be turned off before This plan ensures that data is always safe, even in case you
running a malware scan, because after the system is disin- need to format the operating system residing in drive C.
fected, it restores partition, and if left intact, it might inad-
vertently restore the malware back, like the proverbial What if one has not foreseen this problem or, for example,
phoenix. you have valuable data on the desktop, which by default is
part of drive C and the system refuses to boot. Formatting
Do a full system anti-malware scan in safe mode in such circumstances would lead to irrecoverable data loss.
(with updated definitions) In this scenario, boot the system from a compact disk drive
Once you have entered the safe mode and turned off using a bootable operating system disk (live compact disk)
system restore, run a full system anti-malware scan with such as Linux Ubuntu or Knoppix. A list of bootable oper-
updated definitions. Alternatively, run a DOS based anti- ating systems is available at The Live CD List (see Box 2.1).
malware scanner such as ESET NOD32 antivirus (see Box Booting from the live disk may require changing the boot
2.1). The advantage of DOS-based scanners is that one does order in the BIOS (Basic Input/Output settings). The
not need to load the operating system. These scanners make primary function of the BIOS is to identify and initialize
it possible to scan from the DOS mode, thus making all system component hardware (such as the video display
system files (even the critical ones) available for the scan. card, hard disk, and floppy disk), when the computer is
This method is similar to physically connecting the system powered on. A specific boot order is followed when the
disk to a different computer and doing a ‘scan from the BIOS searches for the operating system. For example: (1)
outside’. Local hard disk, (2) CD drive, and (3) floppy drive. Booting
from a live CD requires that the CD drive is designated as
Install and run a temporary file cleaner and the first boot option in the BIOS. To change the BIOS set-
standalone malware shredders tings, press the key designated for BIOS setup at the startup
This step can be done before or after running the anti- screen; in Figure 2.12b, this is the ‘Del’ key. Once you have
malware scan. These utilities remove the unnecessary files logged in, you can access the local hard disk drives and after
called temporary files that Windows generates in the course successfully doing so, it becomes a matter of common sense
of operation. Several freeware, such as Windows Clean Up to transfer the data to portable media such as an external
and Piriform cleaner, are available (see Box 2.1). In addition hard disk drive.
to these, it is prudent to run standalone malware shredders
such as Stinger, browser hijackers such as Hijack This, and Data backup and recovery
rootkit revealers such as Ice Sword (Box 2.1). This function
ensures disinfection of malware that goes undetected in the Backup
standard malware scan. One could also run an online scan Electronic data loss is an ever-present risk associated with
at major antivirus provider websites such as ESET and newer technology owing to malware infection, and software
Symantec, among others. or hardware failure. The best way to ensure safety is to
conduct routine backups of important data onto physical
Some PMS and EMR solutions have integrated intrusion media (onsite) or over the internet into a secure web server
detection software, which runs in the background scanning (offsite). Backing up direct data (such as images or standard
for security breaches that might compromise patient data files) onto a physical medium such as a hard disk drive or
privacy such as a Trojan horse. On detection, the PMS/EMR a compact disk is a simple matter of copying the files.
will refuse to run, and will notify the user that the system However, copying programs or the status of an entire
is compromised. Privacy compliance for electronic patient system (along with the operating system and installed pro-
data is paramount in laws such as the HIPAA (Health grams) requires full system screenshot or a ghost image of
Insurance Portability and Accountability Act) and HITECH the system, so that in the event of a system failure there is
Act (Health Information Technology for Economic and no need to reinstall program files. To generate a ghost
Clinical Health Act) in the USA and patient data intrusion image, special programs such as Norton Ghost or Acronis
may have serious implications. A particular example that is true image (see Box 2.1) are required. The ghost images
often cited with regard to breached security involved a bank generated by these programs may be used to restore the
officer who used a database of cancer patients to call in entire state of an operating system, along with the associ-
loans (Sweeney, 1997). ated programs and data, at the time the ghost image was
created. These ghost backup files can be stored on- or

32  Integrated Clinical Orthodontics

offsite. Websites such as Oaktreestorage.com and offsite running Microsoft Windows operating system are shown
backup solutions.com (see Box 2.1) provide an algorithm in Table 2.7.
wherein each large file is divided into 100 or more parts and
each part carries a ‘marker’ indicating whether anything Virtual patient record for integration
within that 1/100 has been modified since the last time. of specialties
Therefore, only portions that have been modified are
reuploaded. This process is termed incremental backup Over the years, electronic medical records/EPRs have
(Redmond, 2008). evolved to help healthcare providers with structured and
helpful information. However, most electronic record
Recovery of lost data systems associated with a specific specialty are independent
Some programs enable the user to recover deleted data or and isolated and do not communicate with other special-
data from formatted disks, such as Recover my files or Data ties, thus effectively addressing the specificities of that spe-
recovery doctor (see Box 2.1). However, the disk should be cialty alone, rather than the patient as a whole. Patients
physically intact to attempt recovery. Especially important receive services which are provided by numerous specialists
is image recovery from memory cards used in digital and institutions, including healthcare professionals, hospi-
cameras, lost due to accidental deletion/corruption/for- tals, outpatient care services, drug stores, and interdiscipli-
matting. The following are certain circumstances, which nary healthcare workers such as nurses and laboratory
can lead to such a situation. support personnel. For the benefit of the patient, these
heterogeneous working groups need to be monitored for
• Failure to ‘safely remove’ the memory card. Corruption of coordinated activities with an excellent, workable, user-
the files usually occurs when there is a physical separa- friendly communication system.
tion of the card when a transaction is in progress, espe-
cially during image transfer. However, this error might Integration of healthcare information systems is essential
no longer pose a problem when ‘hot swap’ device stand- to improve communication and data use for healthcare
ards become more widely available. This problem is also delivery, research and management. Integrating data from
heterogeneous sources is an uphill task, because the indi-
• not an issue with wireless transfer of images. vidual feeder systems usually differ in several aspects, such
Accidental deletion of the images. This mistake usually as functionality, presentation, terminology, data represen-
occurs in large setups, where the same digital camera is tation, and semantics (Lenz and Kuhn, 2003). The vision
shared by many operators. This problem can be over- of seamless healthcare is based on integrated healthcare
come by enabling autotransfer in a wireless image trans- processes enabled by seamless information technology
fer setup (Revankar et al., 2010), which transfers the IT support. Realizing the vision of seamless healthcare
images wirelessly to the paired computer, as and when requires the establishment of basic communication infra-
they are shot. However, this corrective move does not structure. Once this network infrastructure is set up, the
eliminate the possibility of images being inadvertently interoperability is based on the adoption of standard data
deleted on the computer. Better still, if the images do not formats at each feeder level. Syntactical standards are meant
require editing (which is unlikely in our scenario), wire- for the correct transmission of medical and administrative
lessly print your images through a paired printer, using data between heterogeneous and distributed medical infor-
PictBridge, without the need for an intermediate mation systems. These standards are mainly HL7/CDA
computer. (Health Level Seven/Clinical Document Architecture),
DICOM, and UN/EDIFACT (United Nations/Electronic
• Accidental formatting of the card. Data Interchange For Administration, Commerce and
• Physical damage to the card. Transport).

Several commercial software programs are available for Semantic standards, on the other hand, ensure correct
recovering lost images from deleted/corrupted/formatted interpretation of the content of the electronically exchanged
memory cards. Most of these programs are shareware, data. Established standards are LOINC (Logical Observation
requiring their purchase. Some freeware for computers

Table 2.7  Comparison of three image recovery software programs

Software Supported file formats Supported operating systems Recovery from formatted cards Recovery from damaged cards
JPEG, TIF Yes No
Picajet photo recovery JPEG, TIF, DNG Windows NT, 2000, XP Yes Yes
Artplus digital Windows Vista, XP, 2000,
photorecovery JPEG 98, Me, NT Yes No
Photoextractor Windows NT, 2000, 2003 XP

Effective Data Management and Communication for the Contemporary Orthodontist  33 

Identifiers Names and Codes), SNOMED (Systematized 2) (HIPAA Law, 2009). There are two possible methods for
Nomenclature of Medicine), and MeSH (Medical Subject encrypting emails:
Heading). Following data standards when implementing
healthcare information technology networks will ensure • Use of web-based encrypted mail providers – ASP
seamless integration of EPR, from diverse systems into a • Use of desktop-based email encryption.
single centralised repository, thus providing a holistic
approach to healthcare. The central database may be Web-based encrypted mail providers
accessed by patients, various healthcare providers, insur- Many web-based email providers offer encrypted email
ance agencies, and government regulators. Protection services (ASP). The following providers are sufficiently
of patient confidentiality in such an environment requires competent to handle EPHI and its transmission (basic
the enforcement of certain technical constraints. These service is free to use):
include authentication (ensuring that the user is indeed
an authorized user), access control (allowing users • www.hushmail.com
access only to information that they need to know), and • www.imedicor.com.
auditing (keeping a record of who has accessed what). For
example, insurance agencies are allowed access to only the This model utilizes a third-party hosted mail client for
treatment procedures carried out and the fee for each secure delivery of email. The message is transmitted via
procedure. secure transmission protocols, between the client web
browsers and delivered to the ASP-hosted mail server, while
HIPAA compliance for electronic protected a notification message is forwarded to the intended recipi-
health information (EPHI) ent. The intended recipient then actively requests delivery
of the message at the secured ASP-hosted mail site. The
Health information transmission via email is a standard advantage of this method is that confidential and authen-
mode of communication between orthodontists and ticated exchanges can start immediately by any internet
other colleagues, as well as with healthcare companies. user worldwide, since there is no requirement for installa-
HIPAA was enacted in 1996 to regulate the availability, tion of any software, nor to obtain or to distribute crypto-
confidentiality, integrity and usage of patient electronic graphic keys beforehand.
protected health information (EPHI). Standard emails
result in transmission of unsecured PHI. An email message Desktop-based email encryption
bound to a particular destination may cross anywhere There are several dedicated clients available for desktop-
between three and 10 or more internet service provider ISPs based email encryption, with their own dedicated email
or mail relay systems before it reaches its final destination, servers, as well as those which provide encryption add-ons
providing ample opportunity for interception and tamper- for existing desktop email applications such as Outlook
ing. Transmitting unsecured PHI poses a legal risk to the Express and Mozilla Thunderbird (Table 2.8). This method
orthodontist, and to any other involved party, by endanger- is based on the public key encryption architecture. In public
ing the patient’s privacy. key encryption, two keys are generated by every user – one
is the public key and the other is a corresponding private
Email encryption is a mathematical exercise that hides key (Rubin, 1995). The public key is to be distributed,
information in plain sight. Encryption applies mathemati- whereas the private key is kept confidential. In this method
cal formula/manipulation to the email message (including of encryption, you can send encrypted emails to anyone
attachments), so that the message contents are hidden from who has sent you their public key. Similarly, anyone who
everyone except the recipient. The fact that we are transmit- has your public key can send you encrypted messages. Only
ting email messages without any encryption means that we the owner of the private key corresponding to the public
are transmitting unsecured EPHI (HIPAA, 2009a). key will be able to decrypt and read the messages, thus
providing ‘confidentiality’. One can also attach digital sig-
HIPAA is a set of federal regulations that requires health- natures to emails using the private key, and the recipient
care organizations and businesses that handle confidential can ascertain that the email was indeed sent by the person
patient health information to simplify and standardize data who he or she claims to be, using the sender’s correspond-
exchange, in an effort to protect the security, privacy, and ing public key, thus providing ‘assurance’ against ‘social
confidentiality of that information (HIPAA, 2009b). HIPAA engineering’. Digital signatures help prevent impostors
established a set of uniform standards for the privacy of from sending emails that appear to have come from you
PHI, which encompass electronic, oral and printed data or (Figure 2.13).
exchange of individually identifiable health information.
On violation of the guidelines, HIPAA imposed penalties Privacy protection on non-internet-
ranging from ‘[US]$100 per violation, up to $25 000 per connected computers
year for each requirement violated’. Criminal violations can
result in penalties ‘from $50 000 in fines and one year in When patient data are stored on a standalone computer or
prison, up to $250 000 in fines and 10 years in prison’ (Weil when communications occur within one’s own local area

34  Integrated Clinical Orthodontics

Table 2.8  Desktop-based HIPAA-compliant email clients

Software License Standalone Website

Private Mail Freeware Yes – works with Hotmail www.trusttone.com/
Mirracrypt Shareware No – plugin for Outlook 2003 and 2007 www.mirrasoft.com/
Mirramail Shareware Yes – works with any email service provider www.mirrasoft.com/
Stealth Freeware No – plugin for Outlook 2003 and 2007 www.trusttone.com/

Digital signature–using sender’s private key Signature verification–using sender’s public key

Receiver’s Encrypted
public key email

Encrypted TLS Decrypted
email email

Plain email Receiver’s
private key
Sender
Figure 2.13  Public key encryption architecture. TLS, transport layer security. Receiver

network (LAN), it does not necessarily require encryption. encryption utilities. A simple to use freeware is AxCrypt
However, these computers should be secure enough by (Axantum Software AB, Järfälla, Sweden). AxCrypt is driven
allowing authorized password access to maintain HIPPA by 128-bit AES (advanced encryption standard), secure
compliance. These systems should have 30-day password enough for all nonclassified data as well as classified data
changing policies in force. To ensure total privacy compli- up to the ‘secret level’ (AES, 2010).
ance, all computer systems should enforce authentication,
access control, and auditing (as discussed earlier). These Conclusion
three features should be integrated in any software that
handles EPHI, including PMS and EMR solutions, to be Technology is complementing traditional communication
HIPAA compliant. methods in all aspects of orthodontics, but the enunciated
role of technology is to enhance, not substitute, the role of
Workstations used for storage and transmission of EPHI personal interaction. Information technology applications
must contain an updated virus scan, updated operating and data management systems for orthodontics continue
system patches, and an anti-spyware product with appro- to evolve rapidly. The goal of wise implementation of these
priate firewalls. When a workstation is no longer used for systems in orthodontics is to amplify the effectiveness of
EPHI storage or is decommissioned, the data on that system the system as a whole.
should be completely erased by special procedures such as
low-level disk formatting to ensure data are completely In the orthodontic team, all of the participants need to
removed from all sectors of the hard disk. All workstations be informed and engaged for smooth running of the system.
should have antitheft measures in place. In case of theft, the Most of the applications described in this chapter are
concerned government agency should be notified along required for the smooth functioning of today’s orthodontic
with all patients whose EPHI is stolen if the data were not offices. Practitioners should develop a comprehensive plan
encrypted. Therefore, it is wise to encrypt all EPHI even for implementing or updating the IT infrastructure in their
though HIPAA does not specify this for standalone work- offices. Issues to be considered in technology purchasing
stations. However, all EPHI on removable and portable decisions include usability, integration, work flow support,
media such as laptops, tablets, handhelds, thumbdrives, cost–benefit analysis, and compliance with acts such as the
floppy disks, and compact disks should be encrypted. HIPAA and HITECH. An all-in-one solution, probably
Encrypting large folders or entire drives requires dedicated ASP-driven (no maintenance), for practice management,