CON-01: TREATMENT CONSULTATION CHECKLIST

Transcription

1 CON-01: TREATMENT CONSULTATION CHECKLIST Date: Practice: Name: Position: 1. Gather materials for the Patient Treatment Consultation: Current study models Current diagnostic photographs Current panoramic radiograph Current cephalometric radiograph and tracing with measures Current periapical radiographs of upper and lower canine to canine area Patient s Treatment Record and chart folder Consultation letter listing the doctor s findings and analysis of records, treatment recommendations, and fee options List of completed Risks of Treatment Consent form Patient Instructions and oral hygiene materials Dentoform showing perfect occlusion Set out examples of appliances or photographs o Dentoform showing braces o Headgear, expander, retainers o Separators, ligature ties, closing chain Diagnosis Form with Consult checklist 2. Greet your patient and parent, introduce yourself, and guide them to the Consultation Area. 3. Review the purpose of the appointment and give a short overview of what you will be doing. 4. Show the photographs, models, panorex, periapicals, and cephalometric measures. 5. Using the patient s records review the diagnostic concerns as outlined by the doctor. 6. Explain the treatment options and the advantages and disadvantages of each option. 7. Discuss the proposed treatment plan and address the concerns of the patient and parent. 8. Review the risks of treatment and give the patient and parent a full explanation of the seriousness of each risk as expected from the proposed treatment for the patient. 9. Have the patient or parent sign the Treatment Risks form and the Consent form. 10. Review the New Patient Instructions, explain the patient-controlled factors, and have the patient and parent sign in the appropriate area. 11. Discuss financial arrangements and select a payment plan. 12. Schedule the next appointments. 13. Complete all paperwork. CON-01 Treatment Consultation Checklist International Training Institute Page 1 of 1 Page 1 of 14

2 Name: Exam Date: M/D Age: Dentist: Records: Age: CC: Attitude: Time/Moving Pbs: Med Hx: Growth: Dent Hx: Teeth: Primary, mixed, permanent, missing Pan date: Resorp: Root shape: Leew: Full erupt: TMJ: OK 7 s year 8 8 Other: 8 8 DX: Class Dental: Skeletal: Other: TREATMENT OBJECTIVES 1. Skeletal Class Dental Class OJ Ideal Level to ideal OB Align 4. Transverse: Widen MLs on 5. TREATMENT ALTERNATIVES Advantages Disadvantages Consult Date: Init Present: M D P Init Time Req: X Fluoride Rx/Peridex Ext. of Teeth 8 8 Soon Retention:Hawleys Clear Bonded X Later 8 8 Sulcus Slice Dental Care X Frenectomy La La Li Oral Hygiene X Gingivoplasty Diet & Appl. Care X Surgery Coop: HG, EXP, CBJ, EL X Bolton Vacations X Perio: Gingivitis Recession Bulk X Retainers X Resorption X Appointments X Decalcification Present Broken Appointments X Restorative Emergency Number X TMJ X Results Anticipated: 1 = great 2 = good 3 = limited Limitations Facial / Skeletal Result Foster Overall Positive Self-image Optimal Dental and Smile Result Shortest Treatment Time Optimal Occlusal Result Minimal Discomfort Optimal TMJ and Myofacial Result Noncompliance Biomechanics Optimal Perio Health Cooperation Dependent Optimal Stability Growth Dependent Page 2 of 14

3 COMPREHENSIVE TREATMENT Patient: Age: years months Date:_ The doctor has completed an analysis of the orthodontic records and has found the following areas of concern: Overbite Underbite Jaw relationship problem: lower jaw underdeveloped upper jaw underdeveloped lower jaw overdeveloped Expected jaw growth limited or unfavorable direction Crossbite Arch constriction or narrow arch form Back teeth not lined up Midline shift Asymmetry Excessive gum showing with smiling Openbite Tongue thrust habit Excessively deep bite Wear of teeth Crowding of the teeth Spacing of the teeth Rotations of the teeth or malalignment Missing teeth High root resorption potential Oral hygiene Gum concerns: frenum recession bulk TMJ signs or symptoms or history of problems Other The doctor s treatment recommendations are: Comprehensive-Full Orthodontic Treatment with Full braces Headgear: Type: Hours: CBJ Growth Appliance Expansion Palatal holding arch Lower lingual arch Habit appliance: Bite buttons Extraction of teeth: Frenectomy, gingivoplasty, gingival graft, or other periodontal therapy Elastics Other: One set of retainers and supervision of retention for two years Anticipated limitations of treatment are: The anticipated length of this treatment is months and the treatment fee is $ which can be paid: 1. With a downpayment of $ and a contract for months for $ per month. 2. With a 6% reduction of the fee for payment in full at the beginning of treatment by either cash or check. Fee reduction is $_ for a total of $. 3. With a 3% reduction of the fee for payment in full at the beginning of treatment by credit card. Fee reduction is $ for a total of $_. Diagnosis and Treatment Planning - International Training Institute Page 3 of 14

4 PHASE I TREATMENT Patient: Age: years months Date: _ The doctor has completed an analysis of the orthodontic records and has found the following areas of concern: Overbite Underbite Jaw relationship problem: lower jaw underdeveloped upper jaw underdeveloped lower jaw overdeveloped Expected jaw growth limited or unfavorable direction Crossbite Arch constriction or narrow arch form Back teeth not lined up Midline shift Asymmetry Excessive gum showing with smiling Openbite Tongue thrust habit Excessively deep bite Wear of the teeth Crowding of the teeth Spacing of the teeth Rotations of the teeth or malalignment Missing teeth High root resorption potential Oral hygiene Gum concerns: frenum recession bulk TMJ signs or symptoms or history of problems Other The doctor s treatment recommendations are: Phase I-Early Orthodontic Treatment which will consist of: Limited braces Headgear: Type_Hours: CBJ Growth Appliance Expansion Palatal holding arch Lower lingual arch Habit appliance: Bite buttons Extraction of teeth: Frenectomy, gingivoplasty, gingival graft, or other periodontal therapy Other Temporary retainer(s) Supervision until full eruption of the teeth Phase II (full orthodontic treatment) may be needed in the future Anticipated limitations of treatment are: The anticipated length of this treatment is months and the treatment fee is $, which is paid with a downpayment of $ and a contract for months for $_ per month. The fee can also be paid in full at the beginning of treatment, or with an alternative payment plan. Diagnosis and Treatment Planning - International Training Institute Page 4 of 14

5 PHASE II TREATMENT Patient: Age: years months Date:_ The doctor has completed an analysis of the orthodontic records and has found the following areas of concern: Overbite Underbite Jaw relationship problem: lower jaw underdeveloped upper jaw underdeveloped lower jaw overdeveloped Expected jaw growth limited or unfavorable direction Crossbite Arch constriction or narrow arch form Back teeth not lined up Midline shift Asymmetry Excessive gum showing with smiling Openbite Tongue thrust habit Excessively deep bite Wear of teeth Crowding of the teeth Spacing of the teeth Rotations of the teeth or malalignment Missing teeth High root resorption potential Oral hygiene Gum concerns: frenum recession bulk TMJ signs or symptoms or history of problems Other The doctor s treatment recommendations are: Phase II-Full Orthodontic Treatment with Full braces Headgear: Type: Hours: CBJ Growth Appliance Expansion Palatal holding arch Lower lingual arch Habit appliance: Bite buttons Extraction of teeth: Frenectomy, gingivoplasty, gingival graft, or other periodontal therapy Other: One set of retainers and supervision of retention for two years Anticipated limitations of treatment are: The anticipated length of this treatment is months and the treatment fee is $ which can be paid: 1. With a downpayment of $ and a contract for months for $ per month. 2. With a 6% reduction of the fee for payment in full at the beginning of treatment by either cash or check. Fee reduction is $_ for a total of $. 3. With a 3% reduction of the fee for payment in full at the beginning of treatment by credit card. Fee reduction is $ for a total of $_. Diagnosis and Treatment Planning - International Training Institute Page 5 of 14

6 TREATMENT RECOMMENDATIONS AFTER A PROGRESS EVALUATION Patient: Age: years months Date: _ The doctor has completed a review of progress to date and has found the following areas of continued concern: Overbite Underbite Jaw relationship problem: lower jaw underdeveloped upper jaw underdeveloped lower jaw overdeveloped Expected jaw growth limited or unfavorable direction Back teeth not lined up Crossbite Arch constriction or narrow arch form Midline shift Asymmetry Excessive gum showing with smiling Openbite Excessively deep bite Crowding of the teeth Spacing of the teeth Rotations of the teeth or malalignment Missing teeth High root resorption potential Oral hygiene Gum concerns: frenum recession bulk TMJ signs or symptoms or history of problems Other The doctor's treatment recommendations are: Deband, temporary retention, and recall until full eruption Extention of Phase I-Limited treatment Phase II-Full Orthodontic Treatment This treatment would include: Full braces Herbst Headgear Bionator Expansion Palatal holding arch Lower lingual arch Habit appliance: Bite buttons Extraction of teeth: Frenectomy, gingivoplasty, gingival graft, CFR, or other periodontal therapy Other: Orthognathic surgery One set of retainers, with supervision of retention for two years. Anticipated limitations and considerations of treatment are: The anticipated length of this treatment is months and the treatment fee is $, which can be paid with a downpayment of $ and a contract for months for $ per month. Diagnosis and Treatment Planning - International Training Institute Page 6 of 14

7 Name of Patient: LIST OF POSSIBLE RISKS RESULTING FROM ORTHODONTIC TREATMENT AND LIMITATIONS OF TREATMENT Fracture of a tooth due to large fillings Fracture of tooth due to eating hard foods or trauma Desired skeletal correction not achieved due to: Lack of patient cooperation Lack of growth Lack of growth in proper direction Other: Desired bite not achieved due to: Ankylosis of teeth fused to the bone Lack of patient cooperation Tooth-size problems Primary molars present without permanent teeth to replace them Small lateral incisors, need to enlarge/widen teeth Large lateral incisors Other tooth size problems Other: Decalcification and decay due to: Poor oral hygiene Eating foods/drinks high in sugar Lack of dental cleanings at 3-6 month intervals with wires removed Root canal therapy flare ups Tooth nerve death with darkening of the tooth from unknown cause requiring root canal therapy Gingivitis/Periodontitis with irreversible bone loss due to Poor oral health Other:_ Gum bunching due to fibrous gum tissue Gum recession Root resorption, or excessive root shortening, which decreases the support of the teeth from Canines Trauma _ Unknown cause Increased need for restorative treatment Enlarge upper laterals Other: Sinus preventing movement of upper back teeth TMJ concerns and problems Hormonal changes Stress Bruxism/clenching Other or unknown cause Diagnosis and Treatment Planning - International Training Institute Page 7 of 14

8 Lack of stability of position of teeth (relapse) after the braces are removed Unexpected impaction of teeth Slow eruption of the teeth Longer than anticipated treatment time due to Need for orthognathic surgery due to _ Other: These risks have been discussed with me by Dr. or one of the staff. I am willing to undergo orthodontic treatment understanding these risks or limitations of treatment. Signature of patient/parent Date Diagnosis and Treatment Planning - International Training Institute Page 8 of 14

9 II. Fee payments in the amount stated are due on the first of each month. Monthly statements may be sent on past due accounts. A late payment fee of 1% per month may be charged on past due balances. Practice of: I. The stated fee includes active orthodontic treatment as has been outlined. This fee includes one set of retainers and supervision of retention for two years after Phase II/Comprehensive treatment. This fee includes one set of retainers and supervision to full eruption after Phase I treatment. This fee does not include required oral surgical or other dental services performed outside this office. Additional fees will be assessed for replacement of broken or lost appliances. Page 9 of 14 Date: Patient: Address: FEDERAL TRUTH IN LENDING DISCLOSURE STATEMENT FOR ORTHODONTIC SERVICES RENDERED 1. Professional Fee, Phase I/Phase II/Comprehensive mo. $ 2. Initial Fee $ 3. Unpaid Balance $ Unpaid Balance of $ to be paid in monthly payments of $ beginning III. Payment of all fees under this Contract is the primary responsibility of the patient/parent. All such payments shall be made directly by the patient/parent to our office. We will be happy to assist in preparing necessary forms to help collect benefits from insurance companies, but it shall be the ultimate and primary responsibility of the patient/parent to submit the necessary forms and secure any benefits that may be due. IV. It is understood that during the course of orthodontic treatment, consultation with other medical and dental specialists may be required. With respect to any such consultation for the benefit of the patient, it is agreed that the identity of the patient, information relative to the patient's treatment, and the patient's orthodontic records may be disclosed and made available to any other medical and dental specialists who are consulted. In addition, permission is granted for use of the patient's orthodontic records for other consultations and for professional education and publication, so long as reasonable precautions are taken to guard against the disclosure of the patient's identity. V. It is affirmed that the malocclusion concerns, basic treatment objectives, treatment plan, alternatives in addition to no treatment, risk of adverse effects, probability of success, and expected limitations to treatment have been explained to the patient/parent. Having been so informed, the patient/parent consents to the treatment. VI. We agree to the payment schedule as stated and to perform all of our obligations under this agreement. Patient/Parent Date Orthodontist _ Date

10 PAID-IN-FULL AGREEMENT Re: Orthodontic Treatment Fee Treatment months I, Dr. _, will reimburse if they move midcontract for the amount that would be remaining as if they had paid $_ down and $_ per month for months. Treatment fee totals $_ ($ less 6% bookkeeping courtesy fee of $ for payment in full at beginning of treatment). Parent/Patient Signature Date Dr. _ Date 1. The stated fee includes active orthodontic treatment as has been outlined. This fee does not include required oral surgical or other dental services performed outside this office. Additional fees will be assessed for replacement of broken or lost appliances. 2. It is understood that during the course of orthodontic treatment, consultation with other medical and dental specialists may be required. With respect to any such consultation for the benefit of the patient, it is agreed that the identity of the patient, information relative to the patient s treatment, and the patient s orthodontic records may be disclosed and made available to any other medical and dental specialists that are consulted. In addition, permission is granted for use of the patient s orthodontic records for other consultations and for professional education and publication, so long as reasonable precautions are taken to guard against the disclosure of the patient s identity. 3. It is affirmed that the treatment objectives, plan, alternatives, risk of adverse effect, probability of success and expected benefits have been explained to the patient/parent. Having been so informed, the patient/parent consents to treatment. Page 10 of 14

11 PATIENT INSTRUCTIONS GETTING STARTED! Before braces are placed you will need to have your teeth cleaned. This appointment should be scheduled at least ten days before braces are placed as the bonding agent will not adhere properly if fluoride has been recently applied. You will need to continue to have dental check-ups and cleanings with your general dentist every six months during orthodontic treatment. When you schedule a cleaning appointment, also schedule appointments with us for removal and replacement of your arch wires so a more thorough cleaning can be done. For greater efficiency, we will try to coordinate these appointments with your regular orthodontic adjustment. Following the Consultation, treatment can be initiated by scheduling a Banding appointment and any other preliminary procedures. Banding (placing the braces) will take from 1½ hours to 2½ hours and may need to be preceded by placement of spacers or impressions for other appliances. At the Banding, the initial treatment fee will be collected and a financial contract signed. We will provide you with receipts, payment coupons and other necessary paperwork. APPOINTMENTS After the Banding, monthly adjustment appointments that will generally take minutes will be scheduled at four to six week intervals. Please be on time so patients scheduled after you do not have to wait. If you are more than 10 minutes late for an appointment, we may need to reschedule for another date and time. When arriving for your appointment, please sign in on the computer in the front office, go to one of the brush-up sinks and brush your teeth, then have a seat in the on deck area until you are called back to the operatory. Parents are welcome to help themselves to coffee or tea and reading material and to sit in the front waiting area. Our office is open Monday through Thursday - Office hours are Mondays from 8AM to 3PM, Tuesdays from 8AM to 5PM, Wednesdays and Thursdays from 7AM to 4:30PM. We schedule regular minute monthly adjustment appointments between 7-9AM and from 2PM to the end of our workday, so as many patients as possible can be seen during non-school and non-work hours. (We call these fast lane times!) Repair of loose or broken braces may not be able to be done during fast lane and may need to be scheduled for midday hours. If you are unable to come to an appointment, please inform us 24 hours ahead of time. Every missed appointment can lengthen treatment by one month, since appointments are made four to six weeks in advance and you may not be able to reschedule for the time of day you desire. We will work with you as much as possible without inconveniencing our other regularly scheduled patients. There is an automatic charge of $25 for a third and each subsequent missed appointment. Page 11 of 14

12 CARING FOR BRACES Excellent oral hygiene is very important during orthodontic treatment. Be sure to floss every day and to brush your teeth after every meal and before bed. The doctor may recommend the use of a soft bristle toothbrush and flossing with a floss threader, brushing the gums and around the braces and flossing between your teeth and under the braces. A Sonicare toothbrush can be helpful, and use of a Waterpic for removing loose food debris and massaging the gums. You may also choose to use a fluoride mouth rinse (such as ACT). Fluoride brushing gel will be given at the banding, as well as new toothbrushes and flossing aids. Without good oral hygiene, there is a great risk of gum disease and decay and decalcification around the braces. When you have braces, there are some foods you must avoid: A. Hard and sticky foods can cause brackets to pop off and wires to bend improperly. Each loose bracket means an added month to treatment length. When wires are bent improperly, they move teeth into a wrong position and extra time is needed to move the teeth back into their correct position, extending total treatment time. Some hard and sticky foods to avoid: popcorn (kernels can get stuck under your gums causing pain and swelling), whole nuts, ice cubes, corn-on-the-cob, corn chips, crispy tacos and taco chips, beef jerky, hard candies, pizza with hard crust, gum, taffy, licorice, caramels, Laffy Taffy, Tootsie Roll Pops, popcorn balls, caramel apples and other similar hard/sticky foods. Some foods to cut into bite-size pieces or thin slices: carrots, celery, apples and other crisp fruits and vegetables. While avoiding the above foods, try to stop these habits which can break the braces: chewing on pens, pencils or fingernails, thumb sucking and lip biting. B. All sugary foods should be avoided. Brushing and flossing with braces takes time. Plaque left on the teeth combines with sugar to cause permanent white spots of decalcification around the edges of the brackets. Fluoride brushing gel helps prevent this, but not eating sugary foods or drinking sugary beverages, in combination with thorough daily brushing and flossing, is the very best! C. Highly acidic foods and drinks such as lemon juice, lots of orange juice and soft drinks are hard on tooth enamel and can cause the cement used with some braces to loosen. D. Staining foods (tomato sauce, mustard, coffee, tea, red juices and wines) may cause clear and light-colored ties to discolor. We suggest choosing dark, opaque ties to avoid lots of staining between appointments (we do change ties at each regular appointment). WORKING TOGETHER Cooperation with wearing orthodontic appliances (headgear, expanders, rubberbands, etc.) significantly affects the amount of time braces are needed. The more you wear that headgear or those rubberbands (if you are instructed to do so) the faster your treatment will get done! For each week or month of missed headgear or rubberband wear, a week or a month of additional Page 12 of 14

13 treatment can be expected. The doctor may instruct you to wear these different orthodontic appliances, but no progress will happen unless YOU DO IT!! YOU control how long the braces will be on by your cooperation. The more we work together, the faster we will get you to that great smile! It is important to communicate with our doctors and staff about any concerns or problems you may have with your teeth. There are three particular areas of concern to watch for: A. Jaw joint pain or clicking. If you already have some of these symptoms in your jaw joints, the doctor will be watching carefully for any addition symptoms. Please tell the doctor if you notice any changes. B. Gum tissue recession. The doctor will tell you if you have a tendency for receding gums. Please let them know if you notice any changes in how your gums appear. C. Root resorption. A minor shortening or blunting of root tips can sometimes occur as teeth are moved. In some rare cases, severe resorption may occur and treatment must be stopped early. Teeth will sometimes feel slightly loose as they move with braces, but if your teeth seem extremely loose, please tell the doctor. EMERGENCIES If you have an accident and experience significant pain, swelling or bleeding in your mouth, the doctor s home phone number is _. However, if a wire is poking and causing discomfort, place the wax we have given you over the area and contact our office during regular hours. A loose or broken bracket is also taken care of during regular hours. We have 24 hour voice mail, so a message can always be left and our staff will return your call the next business day. VACATIONS When you and your family are going on vacation, let us know and we will provide a list of orthodontists in the area and a letter of introduction for emergency treatment. Please give us some advanced notice so we can have the information ready for you. RETENTION One set of upper and lower orthodontic retainers and two years of retainer check ups are included in the treatment fee unless otherwise stated. Retainers must be worn full time immediately after the braces are removed to stabilize your teeth while bone re-calcifies around them. This will be discussed in more detail when you received the retainers. (YES, you WILL get there!). TRANSFERRING There is a fee of up to $ for copying and sending transfer records if a patient moves during active treatment. This fee covers the time required to write a detailed transfer report outlining the original malocclusion and diagnosis, treatment procedures to date and future treatment recommendations. Included with this report are copies of models, x-rays and photographs and recommendations for an orthodontist after you move. If a move out of Anchorage is in your future, please let us know so we can talk about it with you and prepare for it. AND NOW IT S TIME TO GET STARTED! Page 13 of 14

14 JOB TITLE: Purpose of job: Responsible to: Financial Coordinator- Follow-up Paperwork after Consultation Accurately recording what occurred at Consult and Preparing Treatment Card Doctor Tasks: 1. Be sure Consent form is signed, noted as such on treatment card. If it is not signed, clip it to the copy of Consultation Letter that is being saved in Financial Paperwork file and have parent/patient sign it when they sign the contract at the start of treatment. 2. Fill out in black ink on treatment card what occurred at Consult ( Consult, Consent Signed, NP Instructions given, Financial arrangements made ). If parent came without the patient note that as well, note in red ink the cleaning date, note anything else that is pertinent to the beginning of treatment. 3. Copy study models on Xerox machine, cut them out and put them on treatment card in appropriate place. 4. Type up treatment plan accurately, as indicated by doctor. Put it on treatment card in the Treatment Plan box. Include need for mouthguard, note the type of brackets to be used if not regular TP V-slot, note if patient will be moving by a certain date, etc. 5. Put one copy of Consult Letter in the patient s file with other financial paperwork, put second copy of Consult Letter in Finances Pending file with class of malocclusion indicated (to use when filling out the superbill), dates of next appointment(s) when financial contract will begin, any other information pertinent to setting up the financial contract. Clip unsigned Consent form to this sheet so it will not be missed! 6. If treatment appointments were not scheduled, put the second copy of Consult Letter in a Treatment to Be Scheduled file alphabetically by last name for easy retrieval when they call to set up appointments. When treatment date is available, file this copy of Consult Letter by date in the Financial Paperwork file. 7. Send any pano copies, extraction requests or correspondence to the general dentist, specialists, other parents as needed. Always record on treatment card in blue ink when something is sent out of the office. As always, never send an original without making a copy! 8. In patient s chart in computer double check accuracy of: a. Responsible Party information (correct spelling of names, check address and phones, etc. b. Referral information c. Patient status, birth date and model box number are correct and in place. Hours required: ½ hour per patient Skills and attitude required: 1. Desire to be accurate in recording information. 2. Knowledge of computer program. 3. Knowledge of Word for typing up tx plan. 4. Desire to follow through with what has been promised/discussed with parents/patient. Page 14 of 14