There are a number of issues involved when responding to a request for a quick orthodontic fix for an older patient.
Adult patients who are prepared to commit themselves to orthodontics will generally not do so lightly. They are mostly compliant and co-operative, and want to be heavily involved in their treatment, often scrutinising every tooth movement. This could be a cue to reassess the level of the patient’s expectations.
During the course of treatment, the clinician may come under pressure from the patient to adapt the original treatment plan. Unless the clinician has sufficient experience, there is a temptation to undertake tooth movements that are clinically contra-indicated, in an attempt to appease the patient.
Undergoing orthodontic treatment as an adult can be costly and time-consuming. Anyone making these sacrifices may have unrealistic expectations, not only of the outcome but also of the impact that straighter teeth will have on other aspects of their life; the stakes can be high. If you are not sure, now is the time to check that the patient’s understanding of the proposed treatment is realistic, and make a note of the conversation in your records.
Clear aligner techniques
The concept of using removable tooth-positioning devices for minor localised tooth movements is not new. Arguably, developments in data technology have facilitated novel techniques for the movement of teeth. These systems can be particularly attractive to a clinician who has little experience in orthodontics, because the treatment plan and a series of aligners are formulated for them by the system provider.
Additional risks are introduced when the clinician is reliant on the computer software and the remote technician who designs and constructs the aligners – effectively taking over the diagnosis and treatment plan without ever seeing the patient. If that service originates outside your own country the risks associated with teledentistry should be considered.
Dentists with little experience in orthodontics are particularly vulnerable, as they may not have the expertise to recognise a treatment plan that is not in the patient’s best interests, or that will require modification. Although the providers of such planning services inform practitioners that they can reject the treatment plan if it is unsuitable, the dentist may not have the knowledge or confidence to question the computer-generated treatment plan. In such circumstances it would be wise to discuss your concerns with a more experienced colleague. Before providing any treatment, always ask yourself: “Am I confident I have the expertise to carry this out?”
Aligner systems rely on patients wearing their aligners for a prescribed number of hours each day. Patients frequently fail to achieve this target, and so discrepancies can develop between the predicted and actual tooth movements that each aligner is expected to produce. An experienced clinician will notice the discrepancy and amend the treatment plan; a less experienced clinician may not.
Having to backtrack through the aligner sequence can be embarrassing for the clinician and frustrating for the patient. Sometimes a fixed appliance is required towards the end of the treatment to obtain the final outcome. If the clinician has not predicted this and discussed it with the patient, there can be disappointment when the patient learns they will have to wear a fixed appliance after all.
All in the name
Using a system with a finite time span in the brand name, for example ‘six month smiles’, can influence patient expectations about treatment time. If consent forms supplied by providers of such systems state that treatment will take between four and nine months, it is easy to see how patients could make assumptions and feel upset if treatment takes longer.
Providers of various orthodontic systems often encourage practitioners to use the consent forms and information leaflets provided. But these forms, while often being helpful as general information leaflets, do not serve as evidence of the consent process. In order to demonstrate validity at a later date, it is essential that the consent process is appropriately documented in the patient’s records, with evidence of the relevant information provided to the patient, including treatment options, the risks and benefits, and any limitations associated with the treatment options. The record should also detail the discussions regarding the patient’s expectations, and whether or not these are likely to be met by the agreed treatment plan, a copy of the treatment plan, and compliance advice provided to the patient, including appliance wear and attendance at appropriate appointments.
Short-term orthodontic appliances have the capacity to apply forces to both the roots and the crowns of the teeth. In some patients there is a possible risk of root resorption. The clinician needs to understand how to assess the risk, which should be discussed separately and recorded in the clinical notes.
As with any type of orthodontic treatment, retention is often required. This needs to be identified, discussed with the patient and factored into the treatment plan from the outset. A less experienced clinician may not recognise the risk of relapse in the original treatment plan, and may fail to obtain patient consent for extended retention. When such information is presented to the patient at the end of treatment, unsurprisingly it can sometimes result in a complaint.
So how can I reduce my risk?
Over the last eight years, Dental Protection has seen an increase in claims and complaints arising from orthodontics. Our advice to aid patient satisfaction and avoid complaints is:
carry out a thorough diagnosis;
- discuss all the treatment options;
- ascertain and manage the patient’s expectations in relation to the treatment, its outcome and retention; and,
- review the treatment as it proceeds and, where necessary, revise the treatment plan and/or seek advice from a more experienced colleague.
Embarking on orthodontic treatment without developing a proper depth of knowledge and understanding of orthodontics could invite problems. There are ever-present dangers when something is a lot easier to ‘sell’ than to do.
- Have I considered all the treatment options?
- Am I confident to provide this treatment?
- Do I have access to a mentor or back-up if required?
- If I need to alter the treatment plan mid treatment, how will I discuss this with the patient? Do I need to prepare them for this from the outset?
Ask the patient:
- What does the patient want from the treatment? A slight improvement, perfectly straight teeth, or a particular tooth movement, e.g., de-rotation?
- Why do they want it now? Is it for a wedding, or other significant event?
- What are they prepared to accept by way of treatment, e.g., removable appliance, fixed appliance?
- How often can they attend? A patient who works away may be less able to attend regularly.
- Are there limitations to the outcome and, if so, does the patient understand this and accept the limitations?
Dr James Foster
BDS MFGDP(UK) LLM
James is a Senior Dentolegal Adviser for Dental Protection, and is part of the team supporting dental members in Ireland.