Essential Guide to Orthodontic Practice Management

PRACTICE
MANAGEMENT
DR ANALHAQ SHAIKH

CONTENT
• INTRODUCTION
• PRACTICE MANAGEMENT
• ORTHODONTICOFFICE
• MARKETING
• ETHICS
• CONCLUSION
• REFERENCES
Dr. ANALHAQ SHAIKH 2

From the very earliest times, humans have been plagued
by dental problems and have sought a variety of means
to alleviate them.

• The first dental healers
were the Physicians,
but by the middle ages
the barber surgeons of
Europe had specialized
in the care of the teeth.
• These practitioners not
only learned by trial
and error but also by
observation.

INTRODUCTION
• Dentistry :a health care profession
• Two fold role :
• to provide health care & service
• to make profit as a small business.

BDS
• Today our profession is looked upon by the public
with respect and admiration.

I swear by Apollo, Asclepius, Hygieia and Panacea, and I take to witness all the
gods, all the goodness, to keep according to my ability and my judgment, the
following oath.
To consider dear to me, as my parents, him who taught me this art; to live in
common with him and, if necessary, to share my goods with him; to look upon
his children as my own brothers, to teach them this art.
I will prescribe regimens for the good of my patients according to my ability and
my judgment and never do harm to anyone.
To please none will I prescribe a deadly drug nor give advice which may cause his
death.
Nor will I give a woman a pessary to procure abortion.
But I will preserve the purity of my life and my arts.
I will not cut for stone, even for patients in whom the disease is manifest; I will
leave this operation to be performed by practitioners, specialists in this art.
In every house where I come I will enter only for the good of my patients, keeping
myself far from all international ill doing and all seduction and especially from
the pressures of love with women or with men, be they free or slaves.
All that may come to my knowledge in the exercise of my profession or in daily
commerce with men, which ought not to be spread abroad, I will keep secret
and never reveal.
If I keep this oath faithfully, may I enjoy my life and practice my art, respected by
all men and in all men and in all times; but if I swerve from it or violate it, may
the reverse be my lot.
Hippocratic Oath

I swear by my conscience, the almighty, and all that held sacred by my
faith, to uphold according to my ability and judgement this code and
covenant.
To regard my duty to the patient as holy and use my art and skill to
alleviate pain and suffering regardless of my considerations:
to recognize my responsibility to the profession, to uphold its honour and
its frontiers:
to refuse to use my knowledge to be used in any ways that is contrary to
the laws of nature and land and shall obey none but the dictates of
conscience and ethics of my profession and to uphold the privileges of
confidence and consent of my patients.
Dental Oath

Open a new
clinic
Join PG
Work in
some clinic/
hospital
Changed the
profession

Orthodontics …………………..
which attracts the largest
percentage of dental
graduates……

• Reasons to take
Orthodontics and
Dentofacial
Orthopedics as
career -
Respected
Be your own boss
It’s a great
opportunity

Advantages of the
orthodontic specialty
• Work with patients for extended periods of time
• Get to know your patients well
• Get to see your patients change over a period of time
• Have the freedom to
enjoy family, hobbies,
and community
activities

• Many of today’s orthodontists are learning
to become great diagnosticians, excellent
wire benders, and motivated researchers!
• We have all probably heard comments
about a medical or dental office where the
doctor has good technical skills but displays
a poor chairside manner or the office looks
good but staff is not friendly and does not
seem to care about the patients.
Peter Sinclair & EllenGrady. AJODO 2001

Most orthodontic training
programs focus on 3 principle
areas –
1. The biologic and
biomechanical
basis of
orthodontics.
2. The principles
and techniques of
clinical
orthodontics.
3. Scientific
principles and
critical thinking.
Dr. ANALHAQ SHAIKH
14

• But the essential 4th element is often missing.
P_ _ _ _ _ _ _ M_ _ _ _ _ _ _ _ T
which is not being taught……… this tends to
result in well trained clinicians who are poorly
trained managers.
R A C T I C E AN A G EM E N

• Gives a brief overview for clinical setup, run a
practice, manage, motivation, marketing.
Everyone has a
different
personality and
therefore,
would apply
these principles
differently.

PRACTICE MANAGEMENT
ATOPICWHiCH HAS NO “READY
MADE MATERIAL”…

DENTISTRY/ORTHODONTICS
BY CHOICE
& NOT BY DEFAULT

CHANGING SCENARIO
Up to 1940s:
• Solo practice
• One-on-one relationship
• Relatively low pressure, and monitarily rewarding
• level of dental sophistication
• Free to charge
1950 - 70 :
• Consumer demand
• Population increased and a greater desire
• Technical advances
Dr. ANALHAQ SHAIKH
19

Mid 1970’s:
• Patients were hard hit
• Manufacturers faced layoffs
Excessive number of graduates
ERA OF
COMPETITION

Through 1970s and 90’s :
• Alternate service providers emerged
• Department of health maintenance organizations (HMO)
The 21st century:
• Change in insurance scheme
• Advanced technologies
• Demanding conscious consumers

Our basic premises are -
1. The primary goal is to get satisfactory outcome.
2. Early treatment has to be a part of futuristic
orthodontic planning since it is essential to
preventive procedures.
3. Orthodontist should be an authority on
occlusion, includingTMJ function.

4. Quantity is not necessarily an enemy of
quality, if quality comes first.
5. Orthodontist needs better communication
with patients, parents, dentists and the
public.
6. Time is one of our most valuable assets.

Weapons in the ORTHODONTIST’S
ARSENAL
1. Functional Appliances
2. OrthopedicAppliances
3. Therapeutic Extractions
4. Distalizing Appliances
5. Orthognathic Surgeries
6. Distraction Osteogenesis
7. Implants as an aid to Anchorage

• The general philosophy in orthodontics is based on
following principle –
1. Effort = Result . The level of effort is the measure
of the result.

2. It is important to make
efficient use of one’s time. We
cannot save time, but we
must spend it wisely.
3. The team approach is also a
component for successful
practice management.
4. The better the product
(service rendered), the
greater the financial reward.

The real key to any successful practice is
having patients who will cooperate.

Why do people seek
orthodontic treatment???

Challenges faced by today’s
practitioner
• Problem of plenty
• Price undercutting
• High real estate price
• Exorbitant inventory cost
• High recurring expenditure
• Man power problem
• Continuous upgradation with knowledge and technology
• Over demanding patients
Dr. ANALHAQ SHAIKH
31

Raise the bar
1. Competition proof
2. Recession proof

Triad for success
• Updated knowledge of success – and
putting it into practice
• Efficient practice management
• Proper finance management

PRACTICE MANAGEMENT
• Survival Phase 2-5 years
• Consolidation Phase approx. till age of 40-
45
• Relaxation (Retirement) Phase

Survival Phase
• Institution attachment
• Visiting practice
• Own stationary practice
• Combination of two or more of the above

Advantages of attachment in a
Teaching Institution
• Helps to be in touch with the latest
developments.
• Fixed income.
• Can practice after college.

Disadvantages of attachment in
a Teaching Institution
• Exploitation
• Loss of efficiency due to excessive travel
time
• Loss of valuable waiting period time in case
the ultimate goal is to start it’s own practice

Advantages of visiting practice
• Less overall responsibility
• More money with less tension

Disadvantages of visiting
practice
• Loss of identity
• More tiring and cumbersome after few
years
• More “SPLITS” in fees, therefore tendency
towards short cuts
• Less financial gain for the amount of effort
put in

Own practice
• Exclusive orthodontic(speciality) practice
• Practice general dentistry along with special
practice

Advantages of own/rented
practice
• Excellent way to develop one’s own identity
• Real estate appreciation
• Less or no split in treatment charges

Disadvantages of own practice
• Waiting period of approx. 1000 days
• Minimum administrative expenses

Consolidation Phase 30-45 years
• Renovating and updating small clinic
• Expanding a small clinic to multiple
operatory
• Having a dental surgeon or associate
• Installing an OPG cum cephalostat
• Multispecialty dental clinic

Transitional office design for Dr. Harry Bussa (2,900 square feet)

Transitional office design for Dr. George Adams (4,000+ square feet)

Floor Plan for a 1000 square foot office

Site Planning
• Office Location
• Areas demographics
• Price of land and overall cost of the project
• Legal restrictions
• Landscape and greenery
• Type of building
• Parking space

Office location
• Choosing an office location can be
complicated and time consuming.
• The most important Q is –
• Where do I want to live ?
• Do I want to practice in a large or
small town ?
49Dr. ANALHAQ SHAIKH

Large towns
50
ADVANTAGES
 More privacy
 More things to do
 More chance for
association
 More potential for
increase in population
 More groups in
which to choose
friends
DISADVANTAGES
× Constant influx of
competition
× Continuing need to
promote your practice
× Harder to get name
recognition
× Higher cost of living
Dr. ANALHAQ SHAIKH

Smaller town
51
ADVANTAGES
 Fewer orthodontists in
town
 Not as much as constant
worry about referral sources
Overhead is less, not as
much staff turn over
More flexibility in
scheduling
 Greater status in the
community.
DISADVANTAGES
× Fewer groups with
which to associate
×Wife may have a
career, & have little
opportunity
× Educational level is
usually less
Dr. ANALHAQ SHAIKH

Physical Layout
• Buildings and alterations are long term
investments and physical structures that
cannot easily be changed; we need to do
some careful research and plan well.
• Some times, it is also beneficial to employ
the services of an architect.

• The ambience and design of the clinic is an
important factor in the success of any
practice.
• The reception room and reception desk
make an immediate impact on the new
patient’s entry into the practice.
Gansberg M. Redesigned office and operatory increase efficiency. J Clinc Orthod. 1973;
8: 508–513p.

Analysis of Location…….???
1. Visibility
2. Traffic count
3. Access from Street
4. Dentists willingness to Refer
5. Cost of Land
6. LOGO & NAME

• A warm atmosphere and decor go a long
way toward establishing a comfort zone for
both parents and patients, who are often
anxious about the initial examination.

The 3A’s
•Accessibility
•Availability
•Ability

Waiting area
• Cleanliness
• Fragrance
• Music
• Audio visual aids

Reception

Phone call
• Courteous
• Fix appointment suitable for both

• Receptionist is the person who makes the
first office contact on phone, so these most
important auxillaries should have following
qualifications;------------
1. Dental auxillaries experience
2. Good telephone voice
3. Physical appearance - according to what
our patient will accept and be pleased
with.

61
1. Phone must be answered promptly.
2. Answer with pleasant and concerned
voice.
3. Listen carefully and obtain all the
information before closing the
conversation.
4. Never discuss fee or financial
arrangements over the phone.
Dr. ANALHAQ SHAIKH

First visit at clinic
• Large reception if possible
• Reflect the attitude of the people working
• Information regarding chief complaint
• Referring doctor/patient if any
• Distribution of educational material

Body language
• Positive attitude with enthusiasm
• Proper dressing
• Proper footwear
• Mild perfume
• Apron
• Soft music
• Proper pen and writing material at specific
place

Operatory Area
• There can be 2 separate operatories –
• One for adolescent patients
• The other for adults
• Adult room :
It is decorated primarily in subdued and
relaxing colors. Hanging plants may be
present.
A separate adult tooth brushing area is
provided.There is an adult on-deck area
where coffee and the morning newspaper are
available.

• Children’s operatory
room –
It is much larger and
colorful room than the
adult area.
The child has various
entertainment choices to
help him enjoy the time
when he is not actually
being treated.

• You cannot rely on the patient’s ability to
judge your skill and quality of care.
• An exceptional office environment and a
warm, caring staff are fundamental if you
want to improve your case acceptance rate
HamulaW. Orthodontic Office Design. J Clinic Orthod. 2000; 34(3): 145–146p.

Office Personnel
• Office manager
• Receptionist
• Chair side Assistant
• Lab technician

• The members of the office are critical to the
performance of a practice.
• Anything done by any staff member is a
reflection on the doctor.
• Therefore, it is most important for the
practitioner to surround himself with
individuals he can rely on, who can share his
same basic philosophies.

Staff
• Neatly dressed
• Apron
• Etiquette in telephone conversation
• Delegation of specific work to each

If you charge Peanuts

Consultation appointment
• Consultation not on DentalChair
• Consultation in non operatory area
• Emphasize the benefits of treatment
• Professional presentation with audio visual
aids
• Show results of similarly treated cases by
you to induce confidence
• Confidently discuss charges looking straight
into the eyesDr. ANALHAQ SHAIKH 72

Consultation Room

• One more advantage is the racial mix of
people, so that each patient has to be
analyzed and diagnosed on his or her own
merit.

MARKETING

• In general marketing is
most often the focus in
highly competitive
environments.
• Also general economic
situation will always
affect the number of
patients seeking
orthodontic treatment.

• Comparing the number of orthodontists 10-20 yrs
ago, there are more number doctors practicing every
year.
• The patient pool is also affected by non-
orthodontists practicing orthodontics.

• Marketing is a process
that enables us to better
understand the needs and
wants of our patients.
• Marketing encourages
people to want our
services as opposed to
someone else’s.

• Offering or promoting a service or product
usually new or out of the ordinary that we want
our consumer to receive.
• Offering or promoting a service or product that
consumer already perceive as desirable. It is
giving them some thing they already want or
enjoy.
ADVERTISING
MARKETING


Marketing Techniques
• INTERNAL MARKETING
• EXTERNAL MARKETING

Internal Marketing
• Internal marketing plays a vital role in any
practice. No orthodontist can survive
without it. It is one thing to produce quality
results.

• Workmanship
• Salesmanship

Equipments
• Proper sterilization protocol
• Use of distilled water whenever indicated
• Regular oiling of equipments as per
manufacturer’s instructions
• Show any equipment which is exclusive n
your clinic

• When people come into the office, they
must believe that they are coming to a
highly qualified practitioner.
• The patient, the parent, and the referring
dentist must be convinced that this office
will take proper care.
• If that image can be created, the practice
will stay busy.

• Internal marketing starts with the patient/parent
first visit.
• Doctor should sit down and talk one-on-one, explain
the problem, and discuss exactly what treatment is
proposed.
• This quality time which allows the patient and parent
to develop confidence in the doctor.

• As treatment progresses, it is important to
continue setting and reaching various treatment
goals. This reinforcement technique prevents
patient burnout.
• However , no matter how enthusiastic the
patient is in early in treatment, after 2 years, he
is usually tired of being lectured to by his parents
and orthodontist.

• Therefore, that special day, the day braces
are removed, should be treated as a very
important day.
• The patient is now prepared for the most
beneficial type of internal marketing.
• After the braces are removed the patient
and parents are shown the pre treatment
photos and models and comparison are
made.

• Parents are extremely happy to see the
results …….
• After seeing the comparison of before and
after treatment, the family will walk out of
the office and want to tell their friends
about their successful orthodontic
experience.

• Responsibility
• Recognition
• Rewards

You don’t get a second chance to
create a good first impression
• Phone call
• Interaction with receptionist
• First interaction with Orthodontist

Time Management
• Punctuality at clinic
• Time efficient treatment protocol (SL
brackets)
• Work delegation both to clinical and non
clinical staff
• Finish maximum work for a particular
patient in one appointment whenever
possible

Unproductivity at clinic
• Mobile phones
• Gossips
• Idiot box
• Browsing net and social sites

Constant UPGRADATION
• Upgrading knowledge
• Equipments
• Record keeping
• Clinic
• Standardization of clinic (certification)

External Marketing
• This simply means by media advertising.
• Both ADA and AAO disapprove of paid
advertising, which is considered
unprofessional.

External marketing
• Showmanship (achievements)
• Practice name (branding)
• Publications
• Mailers
• IOS Web site
• Public awareness (radio)

In Greek, ethos -
The disciplined study of morality.

• As early as 5th century B.C : "Primum non nocere"
("First do no harm"), attributed to Hippocrates.
The main principle we should have “voluntary written
consent ” regarding participation in treatment.

• Main purpose of written consent is to
provide documentary evidence, that
explainations of proposed treatment was
given and consent was sought and
obtained.
• Information to be explained in consent form
1. Benefits
2. Drawbacks and Risks
3. Cost .

3 basic ethical principles -
Respect
for
persons
1. To do no
harm
2. Promote
good
3. Maximize
benefits,
minimize
risks
BeneficenceJustice

• Every doctor starts from
the bottom unless he is
joining an existing
practice, or continuing
his parents practice.

• The orthodontist who
begins his own solo
practice has no
patients, no income, &
a mountain of debt
and doubts.

SERVICE v/s BUSINESS
As a health care
service:
Provide quality
care for the
patient,
following
standards of care
established by
government and
the profession
itself.
Dr. ANALHAQ SHAIKH 108DCNA 1988
As a business:
An enterprise in
which one is
engaged to
achieve a
livelihood, be
productive &
create a profit.

Future of speciality practice
• Solo practice
• Group practice
• Dental / Orthodontic CE programmes
• Dealer / manufacturing Dental materials
• Dental and Orthodontic lab

Patient’s mental attitudes –
These Pt’s are
those who had
bad results with
previous Rx, and
are therefore
doubtful that
anyone can help
them.
110Philosophical Indifferent Critical Skeptical
These group are
those who find fault
with everything.
They are never
happy, & firm
control of these Pt is
essential.
Succesful Rx can be
most Rewarding
They have little
appreciation for
the efforts of
doctor & offer Rx
because of
insistence of their
families.
They require more
time for
adjustment.
They are willing to
accept the
judgement of their
doctor without
Question.
They accept their
doctor will do best
that can be done.
Ideal attitude for
successful Rx
Dr. ANALHAQ SHAIKH

• Effective patient management is the key to
a successful practice.
• But if patient becomes dissatisfied with the
way he is managed during treatment, he
will develop a negative attitude.

THE ART OF DENTAL EXAMINATION
• This simply means being
thorough.
• A complete and thorough
examination will not only enable
us to deliver the best possible
treatment but will also help to
prevent the malpractice suits.

• Actual examination should follow after the consultation
which should be extra oral and intra oral.
• Consider every aspect of dentistry when examining the
patient.
• Expertly record the results of the consultation and
examination.
• Inform before you perform.

• It is important that both the parents be
present at the consultation. They are made
to realize it is a team effort and also we
should make them comfortable and relaxed
enough to ask questions.

• The first requirement for
creating a compliant patient is
that the clinician must believe
in his or her technique, “Your
beliefs are the most powerful
motivational tool - if you can
just learn how to use them.”
• Keeping treatment simple and
executing a step-by-step plan
will make explanation and
monitoring easier.

• After preliminary diagnosis – 4 items are
always covered:
1. It is an extraction or non-extraction case
2. Expected length of treatment
3. Estimated fee range
4. Next appointment for diagnostic records.

• Generally the patient would like the
treatment to be completed as painless and
comfortably as possible and quickly and
efficiently and with the least expenditure of
time, effort and money.
“MAXIMUM DENTISTRY IN MINIMUM
VISITS”

• When the patient/parent agrees for
the treatment, the fee is collected.
• If the patient requires any restorative
procedures, prophylaxis or
periodontal therapy, it should be
performed prior to the onset of the
orthodontic treatment, and
appropriate instructions is given to the
patient.
• The new patient card is then
delivered, this serves to remind the
patient of his next appointment time.

Patient appointments -
• There is an old aphorism about appointments which
holds true : “you run the appointment book, or the
appointment book will run you.”
• If the patient can choose any day he wants to for his
next appointment, the practice loses control.

• This method of scheduling one day at a time also
provides control over the number of patients seen at
each hour of the day.
120
OVESCHEDULING
DOES NOT BENEFIT
THE
PATIENTS ORTHE
PRACTICE
Dr. ANALHAQ SHAIKH

Debonding appointment
• It is the highlight of the day and one of the
most exciting times in a patients life.

• At this time, any frustrations encountered
by doctor and patient during treatment are
forgotten.
• Here the emphasize is that the doctor,
patient and parent all are succeeded.

• The post treatment review is the
wonderful experience for doctor

Child Orthodontic Patient

• “SUCCESS IS PATIENCE WITH
PATIENTS”
• Orthodontist must be patient
with those young people who
have a difficult time following
directions.
• Child patients are young and
developing, they are by no
means perfect.

• The doctor cannot
give up on them. He
must continue to
encourage, motivate,
and praise, even when
the patient makes it
difficult.

Orthodontic management of
medically compromised patients

• Orthodontic procedures generally
perceived to be among the least invasive
and physiological benign of any in the
dentistry.
• However it must be evaluated for potential
risk for medically compromised patients
and orthodontists must be comfortable
with being able to identify patients at risk
and to treat them appropriately.

129
Many of the behaviours associated with non-compliant
orthodontic patients are -
Poor oral hygiene,
Chronic complaining,
Easily fatigued jaw muscles,
Inability to open their mouths wide,
Frequently broken appliances,
Refusal to use appliances,
Frequent missed appointments.
Dr. ANALHAQ SHAIKH

• Rather than considering these patients as
having character defects or poor attitudes,
orthodontists should view them as “turtles
without shells”.

Major risk for medically compromised
orthodontic patients associated with
bacteremias, are caused by
• Band placement and band removal.
• Bleeding and infection cause by mucosal
and gingival irritation.
• Ability of patients with some conditions to
tolerate treatment.

Management
• Communication with patients physicians.
• Aggressive pretreatment and
intratreatment oral hygiene maintenance.
• Prudent use of prophylactic antibiotic
therapy.
• If diagnosis of leukemia or aplastic anemia
is made, removal of existing orthodontic
appliance is mandatory to minimize the risk
of gingival or mucosal irritation ,bleeding or
infection.
• Elastomeric modules are preferred to wire
ligatures.

Patients with Asthma
• It has been suggested that orthodontic
induced external root resorption occurs
with greater frequency in patients with
asthma than in nonasthma population.
• Therefore it would seem prudent for
orthodontist to disclose the increase risk of
root resorption to patients before initiating
the treatment.

Patients with diabetes mellitus
• Orthodontic treatment should be avoided
when diabetes is poorly controlled.
• When diabetes is under control, treatment
can be carried out but periodontal health
should be maintained.
• Proper oral hygiene instructions should be
maintained.

• Duration of treatment should be reduced.
• Effort should be made to avoid any form of
gingival or mucosal irritation.
• Aggressive pretreatment and
intratreatment oral hygiene maintenance.
• Prudent use of prophylactic antibiotic
therapy.
• Elastomeric modules are preferred to wire
ligatures.
• Fixed retainers over removable retainers.

Risk of bacteremia -
• But how orthodontist is related ?

137
Endocarditis Damage to the endocardium
Adherence of platelet and fibrin to subendothelial layer
Development of nonbacterial thrombotic vegetation
Bacteria
Adherence of bacteria to the vegetation and further increase
in the size of thrombus
Multiplication of the bacteria Local & systemic
complication
Dr. ANALHAQ SHAIKH

Orthodontic considerations
• Band placement and band removal.
• Bleeding and infection caused by mucosal
and gingival irritation.
• Scaling procedures.

Motivational Approach
1. Always remember or have a way of reminding
yourself of patients’ names, especially nicknames.
2. Bring up things about patients’ lives at their
visits— not just hobbies and interests, but current
events.
3. Treat all children and adolescents as if they were
adults., Don’t demand cooperation; ask for it.
4. When a visit is over and the patient is dismissed,
give him or her a genuine smile.

Treatment Overruns
1. Poor cooperation
2. Broken appointments
3. Appliance breakage
4. Altering the treatment approach in mid-
treatment
5. Treatment started too early
6. Abnormal eruption of second molars

7. Adult occlusion
8. Open bites with unresolved tongue
thrusts, macroglossia, or skeletal
dysplasia can have greatly prolonged
treatment times.
9. Some impacted teeth
10.Birth defects.

ULTIMATE GOAL
• OWN GOOD CLINIC
• OWN GOOD HOME
• LEASTTRAVELTIME

Conclusion
• Clinical practice is a balance of experience,
and our intuitive clinical experimentation, an
evolving process which shape up our
philosophy of treatment.
• When a good result is achieved, it can be
exhilarating. When good results eludes us, it
can be quite frustrating.

• While there has always
been a difference between
success and greater
success in practice,
i.e., “ONLY THE FITTEST
SURVIVE”
• Competition from other
orthodontists and general
dentists doing orthodontic
treatment has added to
the struggle for survival.

• The key to successful practice of orthodontics
is reexamining our treated patients, carefully
evaluating the results, and then
incorporating our diagnostic skills and
treatment mechanics to minimize the
magnitude of relapse.
• Practice management is not a single exercise.
It is an ongoing procedure – a planning cycle.

“Managing a practice is an art in
itself which everybody has to master
it so as to lead a comfortable,
satisfied life.”

The heights the great men reached
and kept were not attained by
sudden flight. But, they were toiling
upward in the night while their
companions slept.
- H. W. Longfellow

REFERENCES
• Warren H. Orthodontic office design. J Clin
Orthod 2000;34:15-8.
Orthod 2002;36:701-6.
Orthod 2003;37:533-40.
• Howard I. Management and marketing.
Orthodontic office design. J Clin Orthod
2003;37:485-9.

• Gupta A et al. Practice Management-Are
You Really Doing Well? International Journal
of Advanced Health Sciences, November
2014,Vol 1 Issue 7: 24-29.
• Kulshrestha R. Clinical Practice
Management in Orthodontics: An Overview.
Research & Reviews: A Journal of Dentistry
Sept 2016; 7(2): 7-17.
• Al Atta. Total quality management in
orthodontic practice. Am J Orthod
DentofacialOrthop 1999;116:659-60)

• Sinclair PM, Grady EM. Preparing to
practice and manage: A program for
educating orthodontic residents in practice
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