Originl rticle ommuniction prctices nd preferences between orthodontists nd generl dentists Kevin ibon ; hvn Shroff b ; l M. est c ; Steven J. Linduer d STRT Objective: To evlute similrities nd differences in orthodontists nd generl dentists perceptions regrding their interdisciplinry communiction. Mterils nd Methods: Orthodontists (N 5 137) nd generl dentists (N 5 144) throughout the United Sttes responded to n invittion to prticipte in Web-bsed nd miled survey, respectively. Results: The results indicted tht orthodontists communicted with generl dentists using the type of medi generl dentists preferred to use. s tretment complexity incresed, orthodontists shifted from one-wy forms of communiction (letters) to two-wy forms of communiction (phone clls; P,.05). oth orthodontists nd generl dentists reported tht orthodontists communiction regrding white spot lesions ws indequte. When treting ptients with missing or mlformed teeth, orthodontists reported tht they sought input from the generl dentists t higher rte thn the generl dentists reported (P,.005). onclusions: Orthodontists nd generl dentists perceptions of how often specific types of medi were used for interdisciplinry communiction were generlly similr. They differed, however, with regrd to how dequtely orthodontists communicted with generl dentists nd how often orthodontists sought input from generl dentists. The methods nd extent of communiction between orthodontists nd generl dentists need to be determined on ptientby-ptient bsis. (ngle Orthod. 2015;85:1042 1050.) KEY WORDS: Orthodontist; Generl dentist; ommuniction INTRODUTION Referrls from generl dentists ply n importnt role in the success of n orthodontic prctice. Understnding why generl dentists refer to specific orthodontists is very importnt in tody s competitive environment. Previous studies hve highlighted wht fctors re importnt to generl dentists when choos- Privte Prctice, Richmond, V. b Professor nd Grdute Progrm Director, Deprtment of Orthodontics, Virgini ommonwelth University, Richmond, V. c ssocite Professor, Deprtment of iosttistics, School of Dentistry, Virgini ommonwelth University, Richmond, V. d Professor nd hir, Deprtment of Orthodontics, Virgini ommonwelth University, Richmond, V. orresponding uthor: Dr hvn Shroff, Deprtment of Orthodontics, VU School of Dentistry, 520 North 12th St, Suite 111, Richmond, V 23298 (e-mil: bshroff@vcu.edu) ccepted: Jnury 2015. Submitted: November 2014. Published Online: Mrch 9, 2015 G 2015 by The EH ngle Eduction nd Reserch Foundtion, Inc. ing n orthodontist for referrls, including qulity of cre, cost, convenience, reputtion of the orthodontist, ptient stisfction, nd communiction with the orthodontist. 1 4 ecuse of the estblished significnce of communiction, it is importnt tht orthodontists know how to provide generl dentists with the informtion they desire. 2009 survey indicted tht 75% of generl dentists plce equl importnce on the overll stisfction of the ptient nd the resulting occlusion nd function, lthough their finl referrl decision is bsed on their own opinion of orthodontic tretment outcomes. 3 The dentist likely wnts to understnd the orthodontic tretment objectives nd pln, especilly if the ptient requires extrctions, the restortion of mlformed tooth, or the replcement of missing tooth. Despite some ttempts to systemticlly determine which teeth should be extrcted during extrction therpy 5,6 nd the widespred understnding of the vilble tretment options to restore or replce deformed or missing teeth, 7 12 it is importnt tht both the orthodontist nd generl dentist gree on the ultimte tretment gol so ech provider cn fcilitte its ttinment. ngle Orthodontist, Vol 85, No 6, 2015 1042 DOI: 10.2319/111714-826.1
OMMUNITION ETWEEN ORTHODONTISTS ND GENERL DENTISTS 1043 Figure 1. Flow chrt depicting how the questions regrding types of communiction sent, received, or preferred to receive were divided. One re in which proper in-tretment communiction is prmount is orl hygiene. Despite orthodontists emphsis on good orl hygiene since the 1930s, 13 white spot lesions (WSLs) continue to be common finding in orthodontic ptients. Studies hve shown the prevlence of WSLs to fll between 25% nd 97%. 14 16 lthough 66% of generl dentists believe the ptient is the most responsible prty for preventing WSLs, 82% plce t lest prt of the responsibility on the orthodontist. 17 Furthermore, pproximtely one-third of generl dentists believe the presence of multiple WSLs t the end of orthodontic tretment negtively influences their opinion of the orthodontist. 18 The content nd frequency of communiction between the orthodontist nd the generl dentist re importnt, s is the medi used to communicte. 2004 study found tht generl dentists prefer to receive communiction from the orthodontist vi mil (89%), phone (60%), in person (21%), fx (17%), nd e-mil (9%). 1 With the dvncement of technology, it is likely tht these preferences hve chnged, s the bility to shre nd gther informtion instntly hs llowed for fster nd more efficient communiction. 19 Despite the importnce of communiction between orthodontists nd generl dentists, comprison between how orthodontists nd generl dentists view the communiction prctices of orthodontists hs not been mde. The purpose of this study ws to evlute similrities nd differences in orthodontists nd generl dentists perceptions regrding their interdisciplinry communiction. MTERILS ND METHODS survey ws developed to exmine orthodontists nd generl dentists perceptions nd preferences of how orthodontists communicte with generl dentists. The survey ws customized for orthodontists nd generl dentists so tht the sme questions were sked nd formulted ppropritely for ech group. It consisted of four sections: demogrphics, types of communiction used nd preferred, dequcy of orthodontists communiction with generl dentists, nd circumstnces when orthodontists sked generl dentists for input. Figure 1 shows how the questions regrding the medi used nd preferred to be used to communicte were divided bsed on cse complexity. fter receiving pprovl from the Institutionl Review ord t Virgini ommonwelth University nd the mericn ssocition of Orthodontists, the survey ws sent to orthodontists (N 5 1,000) nd generl dentists (N 5 1,000). The mericn ssocition of Orthodontists e-miled the survey to orthodontists throughout the United Sttes who were rndomly selected from its dtbse of ctive members. follow-up e-mil ws sent 4 weeks lter to increse prticiption. ecuse there ws no wy to trck who responded to the first e-mil, the recipients were sked in the second e-mil to not prticipte if they hd lredy done so. third prty (Virgini ommonwelth University Miling Service) miled the pper survey, long with return-ddressed stmped envelope, to generl dentists throughout the United Sttes who were rndomly selected from the mericn Dentl ssocition website. The miled surveys were numbered so tht the third prty could trck prticipnts nd mil the survey gin to the dentists who hd not returned the survey 4 weeks fter the originl miling. Responses were summrized using counts nd percentges or mens nd stndrd devitions s pproprite. Unless otherwise noted, either x 2 or repeted-mesures logistic regression ws used for ll comprisons. ll clcultions were done with SS softwre (JMP pro version 10, SS version 9.3, SS Institute Inc, ry, N). RESULTS totl of 137 orthodontists nd 144 generl dentists responded to the survey (response rtes of 13.7% nd 14.4%, respectively). Tble 1 shows the demogrphic ngle Orthodontist, Vol 85, No 6, 2015
1044 ION, SHROFF, EST, LINDUER Tble 1. Demogrphic hrcteristics of the Survey Prticipnts Generl Dentists Orthodontists hrcteristic % No. % No. P Vlue Sex.5347 Women 27 38 24 32 Men 73 104 76 104 Wht type of environment do you prctice in?.9450 Rurl 18 25 16 22 Suburbn 63 89 65 87 Urbn 19 27 19 25 Wht type of prctice do you work in?.0032 Solo prctice 69 96 64 88 Group prctice 31 44 30 41 cdemic 0 0 6 8 Men SD Men SD ge (y) 51.9 9.93 47.1 9.94,.0001 Yers in prctice 24.7 10.28 17.1 10.18,.0001 Nominl responses were compred using x 2, nd continuous responses were compred using t-test. chrcteristics of the prticipnts. The two groups were predominntly mle nd typiclly prcticed in suburbn environment. Slightly fewer orthodontists prcticed solo thn did generl dentists (64% vs 69%, P 5.0032), nd the only respondents who worked in cdemics were orthodontists (6% vs 0%, P 5.0032). Generl dentists who responded were older (men ge 5 52 yers old vs 47 yers old) nd hd prcticed more yers thn the orthodontists who responded (men ge 5 25 yers old vs 17 yers old; P,.0001). Medi Used to ommunicte Tble 2 shows the types of communiction generl dentists sid they ctully received nd preferred to receive from orthodontists nd wht orthodontists sid they sent to generl dentists. The results re divided bsed on cse complexity. Regrding the verge ptient, generl dentists received most types of communiction t sttisticlly similr frequency to wht they preferred to receive from the orthodontists (Figure 2). Letters were the only form of communiction tht ws received t frequency significntly higher thn wht ws preferred (P,.05). However, letters were lso most commonly received nd most commonly preferred to be received by generl dentists. Figure 3 compres the type of communiction generl dentists preferred to receive to the type of communiction orthodontists reported tht they provided for the Tble 2. ctul nd Preferred Medi Received by Generl Dentists nd ctul Medi Sent by Orthodontists for the verge/typicl Ptient nd the omplex Ptient verge/typicl se omplex se Type of ommuniction % omprison No. % omprison* No. Generl dentist: Type ctully received Letter 94 136 83 119 E-mil 26 37 17 25 In person 22 32 37 53 Phone 53 76 74 107 Fx 20 29 13 18 Mobile device pp 2 3 1 1 Other 1 2 1 1 Generl dentist: Type preferred to receive Letter 74 106 57 78 E-mil 35 50 28 39 In person 13 19 36 50 Phone 40 57 60 82 Fx 9 13 7 9 Mobile device pp 0 0 0 0 Other 0 0 0 0 Orthodontist: Type ctully sent Letter 86 118 71 97 E-mil 55 76 54 74 In person 34 47 71 97 Phone 51 70 86 118 Fx 13 18 6 8 Mobile device pp 5 7 3 4 Other 4 5 4 5 The communiction forms were compred within ech prctitioner group nd survey question using repeted-mesures logistic regression nd the Tukey honestly significnt difference. Percentges not shring the sme superscript re significntly different (P,.05). The less frequently used forms fx, pp, nd other were not used in the comprison becuse of the lck of dt, nd ll of these types re grouped together with n superscript. ngle Orthodontist, Vol 85, No 6, 2015
OMMUNITION ETWEEN ORTHODONTISTS ND GENERL DENTISTS 1045 Figure 2. ommuniction regrding the verge/typicl ptient: Wht generl dentists reported tht they received compred with wht generl dentists preferred to receive. *P,.05. verge ptient. Generl dentists preferred to receive letter more thn ny other type of communiction, nd orthodontists reported tht they sent letters with similr frequency (P..05). Generl dentists preferred less often to receive n e-mil (35%) nd t significntly lower frequency thn orthodontists sent them (56%; P,.05). With regrd to the more complex ptient, wht the generl dentists preferred to receive nd wht they ctully received did not lwys coincide. Figure 4 Figure 3. ommuniction regrding the verge/typicl ptient: Wht generl dentists preferred to receive compred with wht orthodontists reported tht they sent. *P,.05. ngle Orthodontist, Vol 85, No 6, 2015
1046 ION, SHROFF, EST, LINDUER Figure 4. ommuniction regrding the complex ptient: Wht generl dentists reported tht they received compred with wht generl dentists preferred to receive. *P,.05. indictes tht generl dentists received letters nd phone clls t much higher frequency thn they preferred (P,.05). Generl dentists received e-mils, in-person contct, nd fxes t similr frequencies to wht they preferred (P..05). Figure 5 shows tht orthodontists reported tht they mde phone clls (86%), sent e-mils (54%), nd met in person (71%) regrding complex ptients significntly more often thn the generl dentists preferred (59%, 28%, nd 36%, respectively; P,.05). However, Figure 5. ommuniction regrding the complex ptient: Wht generl dentists preferred to receive compred with wht orthodontists reported tht they sent. *P,.05. ngle Orthodontist, Vol 85, No 6, 2015
OMMUNITION ETWEEN ORTHODONTISTS ND GENERL DENTISTS 1047 Figure 6. ommuniction preferences nd prctices mong generl dentists nd orthodontists regrding the verge ptient versus the complex ptient. *P,.05. they miled letters t frequency (71%) tht ws not sttisticlly significntly different from tht which generl dentists preferred to receive (56%). The differences between how generl dentists preferred to receive communiction nd how orthodontists communicted bsed on cse complexity re reported in Figure 6. Generl dentists preferred to receive in-person communiction or phone cll t significntly higher frequencies when treting complex ptients compred with when treting verge/typicl ptients (36% vs 13%, 59% vs 40%, respectively; P,.05). The preference to receive letter or e-mil decresed when shifting from n verge/typicl ptient to complex ptient. However, this difference ws significnt only for letters (74% vs 56%; P,.05) nd not for e-mils (35% vs 28%; P..05). The orthodontists showed similr trend in how their communiction prctices chnged with cse complexity. In-person nd phone cll communiction showed significnt increses for complex ptient vs n verge/typicl ptient (71% vs 34%, 86% vs 51%, respectively; P,.05). They lso communicted less frequently by letter or e-mil when working on complex ptient, lthough only the difference in how often letters were sent ws significnt. dequcy of ommuniction oth generl dentists nd orthodontists were sked series of questions regrding how dequtely orthodontists communicted with generl dentists regrding extrctions, ptients poor orl hygiene, nd the development of WSLs during orthodontic tretment. The results re shown in Tble 3. With regrd to how often orthodontists notified the generl dentist when the orthodontist wnted teeth extrcted, orthodontists reported tht they did so t higher frequency thn the generl dentists perceived. Specificlly, 74% of orthodontists sid they lwys notified the generl dentists wheres only 56% of generl dentists reported tht they lwys received notifiction (P 5.0036). When sked bout the dequcy of communiction regrding poor orl hygiene, the difference between the responses of the two groups ws smll but sttisticlly significnt. ccording to the findings, 47% of the generl dentists reported tht orthodontists communicted indequtely wheres 53% sid they did so dequtely. This ws in contrst to the 54%, 43%, nd 2% of orthodontists who reported tht they communicted bout poor orl hygiene indequtely, dequtely, nd excessively, respectively (P 5.0399). Most of the respondents in both groups greed tht the level of communiction regrding the development of WSLs ws indequte. The generl dentists were more disstisfied, with 70% compred with 57% of orthodontists reporting tht the communiction ws indequte (P 5.0109). ircumstnces When Input Ws Sought From Generl Dentists The generl dentists nd orthodontists were sked group of questions bout wht percentge of the time orthodontists sked generl dentists for input regrding specific clinicl situtions. Tble 4 summrizes the results. ngle Orthodontist, Vol 85, No 6, 2015
1048 ION, SHROFF, EST, LINDUER Tble 3. dequcy of ommuniction Generl Dentists Orthodontists % No. % No. P Vlue Wht percentge of the time re you notified by your orthodontists/do you notify your referring generl dentists when teeth re to be extrcted for orthodontic resons?.0036 0% 1 1 0 0 1% to 25% 13 18 6 8 26% to 50% 4 5 2 3 51% to 75% 5 7 4 5 76% to 99% 22 31 14 19 100% 56 80 74 98 How dequte is the communiction you receive/provide regrding ptient s poor orl hygiene?.0399 Indequte 47 66 54 74 dequte 53 75 43 59 Excessive 0 0 2 3 How dequte is the communiction you receive/provide regrding ptient s developing white spot lesions?.0109 Indequte 70 100 57 77 dequte 30 42 41 56 Excessive 0 0 2 3 The two groups were compred using t-test on the first question nd likelihood rtio x 2 on the second nd third questions. Orthodontists reported tht they sked for input from generl dentists when treting ptients with mlformed teeth t higher rte (56.9%, SD 5 36.7%) thn the generl dentists reported (40.9%, SD 5 37.9%; P 5.0004). Furthermore, 49% of generl dentists sid tht orthodontists sked for their input 25% of the time or less wheres 46% of the orthodontists sid they sked for input 75% of the time or more. When treting ptients with missing teeth, orthodontists gin reported tht they sked for input from generl dentists t higher rte (62.0%, SD 5 32.0%) thn the generl dentists reported (48.7%, SD 5 38.8%; P 5.0019). Only 1% of orthodontists reported tht they never sked for input, wheres 19% of generl dentists reported tht they were never sked for input. The orthodontists nd generl dentists greed on the frequency tht orthodontists sought input when orthodontists were pproching the end of tretment nd could not obtin idel results. Ech indicted tht this occurred roughly 44% of the time (P..9). Tble 4. Percent of Time Orthodontists sked Generl Dentists for Input Generl Dentists Orthodontists % No. % No. P-Vlue Percent of time orthodontists sked generl dentists for input when treting ptients with mlformed teeth.0004 0% 22 32 7 9 1% to 25% 27 38 26 35 26% to 50% 13 18 10 14 51% to 75% 13 19 12 17 76% to 99% 8 11 28 38 100% 17 25 18 24 Percent of time orthodontists sked generl dentists for input when treting ptients with missing teeth.0019 0% 19 28 1 2 1% to 25% 20 29 19 25 26% to 50% 11 16 16 21 51% to 75% 16 23 20 27 76% to 99% 13 19 28 38 100% 20 29 16 22 Percent of time orthodontists sked generl dentists for input when they re nering the end of orthodontic tretment nd cnnot obtin idel results.9377 0% 26 38 4 6 1% to 25% 20 29 39 53 26% to 50% 10 14 15 21 51% to 75% 11 16 15 20 76% to 99% 15 22 18 25 100% 17 25 8 11 The two groups were compred using t-test. ngle Orthodontist, Vol 85, No 6, 2015
OMMUNITION ETWEEN ORTHODONTISTS ND GENERL DENTISTS 1049 DISUSSION Medi Used to ommunicte The results from this study were both similr to nd different from those of previous study with regrd to how generl dentists preferred to receive communiction from orthodontists. 1 oth studies showed tht generl dentists preferred to receive letter (mil) or phone cll from the orthodontist more thn ny other type of communiction. However, the previous study indicted tht only 8.7% of generl dentists preferred to receive n e-mil, wheres 28% 35% of generl dentists preferred to receive n e-mil in the current study. This mrked increse is likely due to the vst improvements in technology nd more user-friendly interfces tht hve developed since the first study ws published in 2004. The orthodontists nd the generl dentists generlly greed on the mount ech type of medi ws used by orthodontists when contcting the generl dentists for ll types of ptients. These similrities indicted tht generl dentists received nd pid ttention to the orthodontists communiction nd tht the informtion reched its intended recipient. The biggest difference in the reported mounts of ctul communiction ws with e-mil. Interestingly, orthodontists climed to communicte by e-mil t much higher rte thn the generl dentists indicted tht they received e- mils. possible explntion for this discrepncy might be tht the e-mils got filtered into the spm milbox nd were never vilble for the generl dentist to see. lso, if the generl dentist received mny e-mils per dy, there ws the chnce tht n e-mil from the orthodontist got lost in the multitude of e-mils through which the generl dentist hd to nvigte nd ws either never opened or opened nd lter forgotten. nother explntion might be smple bis. ecuse of limittions in obtining the sme type of contct informtion for ll prticipnts, the orthodontists received the survey vi e-mil nd the generl dentists received the survey vi stndrd mil. If the orthodontists responded to survey vi e-mil, it cn be ssumed tht they were comfortble using e-mil s form of communiction. Providing the right form of communiction to generl dentists is delicte blnce for the orthodontist. Not using the preferred form hs its obvious consequences, but using too mny forms could desensitize the generl dentist to the importnce of the informtion communicted. Fortuntely, orthodontists nd generl dentists greed tht the mount orthodontists used ech type of medi to communicte with the generl dentist mtched how generl dentists preferred to receive communiction. For the more complex ptient, the communiction preferences nd prctices for ech group chnged similrly. Generl dentists no longer preferred to receive letter t rte higher thn the other forms nd plced equl weight on receiving phone cll. The orthodontists met this increse in expected communiction. The shift from one-wy to two-wy forms of communiction ws understndble becuse complex ptients often require high levels of coordintion between prctitioners to ensure tht the ptient receives the best possible outcome in timely mnner. dequcy of ommuniction Most generl dentists rted the orthodontists communiction s dequte with regrd to ptients who hd poor orl hygiene yet indequte with regrd to ptients who hd developing WSLs. This ws surprising result becuse poor orl hygiene is precursor to WSLs, so one might hve ssumed tht the communiction prctices would hve been similr. Perhps this difference ws becuse WSLs cn develop in s little s 4 weeks. 20 Even if orthodontists mde the generl dentists wre of poor orl hygiene when it first becme concern, the orthodontists might not hve hd the opportunity to inform the generl dentists bout WSLs if the ptient sw the generl dentist between orthodontic ppointments. Interestingly, most orthodontists rted their own communiction bout poor orl hygiene nd developing WSLs s indequte. Perhps they ttempted to hndle these issues within their own prctice without the help of the generl dentist, or perhps they did not wnt to dmit to the generl dentist when these issues occurred becuse of pride or for legl resons. Regrdless of the reson, this is n re where orthodontists cn improve how they communicte with generl dentists. ircumstnces When Input Ws Sought From Generl Dentists When treting ptients with mlformed or missing teeth, the orthodontists reported tht they sought input from the generl dentists t higher rte thn the generl dentists climed. This difference indicted tht the mngement of missing or mlformed teeth is n re where communiction must be improved. Kokich nd Sper 21 discussed series of questions bout restoring missing nd mlformed teeth tht must be nswered before the removl of brces. 21 ccording to these uthors, consensus cn only be ttined by dequte two-wy communiction between the generl dentist nd orthodontist. ngle Orthodontist, Vol 85, No 6, 2015
1050 ION, SHROFF, EST, LINDUER ONLUSIONS N Orthodontists nd generl dentists perceptions of how often specific types of medi were used for interdisciplinry communiction were generlly similr. When they were different, orthodontists indicted tht ech form of medi ws used t higher frequency thn did the generl dentists. N Orthodontists nd generl dentists did not gree on how dequtely orthodontists communicted with generl dentists nd how often orthodontists sought input from generl dentists. N To ensure the highest qulity of ptient cre, the methods nd extent of communiction between orthodontists nd generl dentists tht is complint with the Helth Iinsurnce Portbility nd ccountbility ct need to be determined by both prties on ptient-by-ptient bsis. KNOWLEDGMENTS This study ws supported in prt by the Southern ssocition of Orthodontists Grdute Student Reserch Grnt. REFERENES 1. Keim RG, Gottlieb EL, Nelson H, Vogels DS III. JO survey of referring dentists. J lin Orthod. 2004;38:219 223. 2. Guymon G, uschng PH, rown TJ. riteri used by generl dentists to choose n orthodontist. J lin Orthod. 1999;33:87 93. 3. Hll JF, Sohn W, McNmr J Jr. Why do dentists refer to specific orthodontists? ngle Orthod. 2009;79:5 11. 4. de ondt, rtmn IH, Zentner. Referrl ptterns of Dutch generl dentl prctitioners to orthodontic specilists. Eur J Orthod. 2010;32:584 554. 5. Tkd K, Ygi M, Horiguchi E. omputtionl formultion of orthodontic tooth-extrction decisions. Prt I: to extrct or not to extrct. ngle Orthod. 2009;79:885 891. 6. Ygi M, Ohno H, Tkd K. omputtionl formultion of orthodontic tooth-extrction decisions. Prt II: which tooth should be extrcted? ngle Orthod. 2009;79:892 898. 7. Miller W, McLendon WJ, Hines F III. Two tretment pproches for missing or peg-shped mxillry lterl incisors: cse study on identicl twins. m J Orthod. 1987; 92:249 256. 8. Schmitz JH, offno R, ruschi. Restortive nd orthodontic tretment of mxillry peg incisors: clinicl report. J Prosthet Dent. 2001;85:330 334. 9. Kokich VG, rbill KE. Mnging the ptient with missing or mlformed mxillry centrl incisors. m J Orthod. 2006; 129(suppl 1):55 63. 10. loss LQ, Reston EG, Tessrollo F, Freits MPM, rolito G. Multidisciplinry pproch in the rehbilittion of missing lterl incisors: new trend in dily prctice. Oper Dent. 2012;37.5:458 463. 11. Kokich VO Jr, Kinzer G. Mnging congenitlly missing lterl incisors. Prt I: cnine substitution. J Esthet Restor Dent. 2005;17:5 10. 12. Shrm, Prk JH. Esthetic considertions in interdentl ppill: remedition nd regenertion. J Esthet Restor Dent. 2010;22:18 30. 13. Strnge RHW. The orthodontist s responsibility to the dentist. ngle Orthod. 1933;3:162 177. 14. Julien K, uschng PH, mpbell PM. Prevlence of white spot lesion formtion during orthodontic tretment. ngle Orthod. 2013;83:641 647. 15. Gorelick L, Geiger M, Gwinnett J. Incidence of white spot formtion fter bonding nd bnding. m J Orthod Dentofcil Orthop. 1982;81:93 98. 16. oersm JG, vn der Veen MH, Lgerweij MD, okhout, Prhl-ndersen. ries prevlence mesured with QLF fter tretment with fixed orthodontics. ries Res. 2005;39: 41 47. 17. Mxfield J, Hmdn M, Tufekci E, Shroff, est M, Linduer SJ. Development of white spot lesions during orthodontic tretment: perceptions of ptients, prents, orthodontists, nd generl dentists. m J Orthod. 2012; 141:337 344. 18. Hmdn M, Mxfield J, Tufekci E, Shroff, Linduer SJ. Preventing nd treting white-spot lesions ssocited with orthodontic tretment: survey of generl dentists nd orthodontists. J m Dent ssoc. 2012;143:777 783. 19. Revnkr V, Gndedkr NH. Effective communiction in the cyberge. m J Orthod. 2010;137:712 714. 20. Ogrd, Roll G, rends J. Orthodontic pplinces nd enmel deminerliztion: Prt 1. Lesion development. m J Orthod. 1988;94:68 73. 21. Kokich VG, Sper FM. Guidelines for mnging the orthodontic-restortive ptient. Semin Orthod. 1997;3:3 20. ngle Orthodontist, Vol 85, No 6, 2015