Orthodontics is a field of dentistry that addresses the diagnosis, prevention, management, and correction of mal-positioned teeth and jaws, as well as misaligned bite patterns. Abnormal alignment of the teeth and jaws is very common. The approximate worldwide prevalence of malocclusion was as high as 56 per cent according to a recent meta-analysis.
During the pandemic, with people working from home and increasingly spending much more time looking back at themselves on screens in virtual meetings, there has been a significant uptick in demands for all forms of cosmetic dentistry, including orthodontics for cosmetic reasons. This is the so-called ‘Zoom boom’.
Any rise in demand unfortunately carries with it a rise in the number of patients who are dis-satisfied with care. At Dental Protection, we see this especially when reviewing more elective or cosmetically driven cases where patients perceive that their expectations are not being met.
We know that most orthodontic cases involve a time span which can be viewed as a patient journey, from initial visit/ referral to fi nish/review. Along that road, there are defi ned ‘pinch points’ in the treatment timeline that can lay the ground for a patient complaint.
So, by way of explaining, I will walk through a potential orthodontic case from start to fi nish highlighting some of the common themes and issues that arise. When referring to the patient, it is assumed that it includes parent/guardian/ responsible person if the patient does not have capacity, such as a minor.
Initial presentation – This involves taking a thorough history and having a good understanding of the patient’s presenting concerns and expectations as the starting point. This should involve taking a history of previous treatments – for example, an adult seeking clear aligner treatment due to relapse of previous orthodontic treatment may signal potential compliance discussions to be had, prior to any further course of care.
Communication – Effective and clear communication is paramount from the start, especially as orthodontic care often involves a signifi cant time span and multiple visits. Building a trusting relationship starts with something as simple as open disclosure about the practitioner’s qualifications – sometimes general practitioners can be the subject of a complaint where the patient reports they were under the impression the dentist was a specialist.
Assessment – The quality and quantity of information gathered should be sufficient to evidence an assessment that is to standard, including consideration of a lateral ceph and analysis of this. Pre-treatment records such as models/scans and good quality clinical photos are prudent practice.
Are there any other dental considerations that may be impacted by treatment – for example periodontal considerations (including gingival biotype), existing recession, previous trauma? If so, this should be carefully assessed and documented and will serve as a baseline reference at the start of care.
If there are sufficient concerns, for example periodontal issues, it may be in the patient’s best interest to undergo treatment or even see a specialist to ensure dental fitness prior to orthodontic treatment.
Diagnosis – This involves putting all of the pieces (history, assessment, special tests) of the puzzle together. Where there is no diagnosis noted, it can be difficult to justify relatively complex treatment.
Options – Following on from diagnosis, are all reasonable options presented (including benefits/risks/limitations/costs of each) appropriate to the case? Including the option of no treatment?
For example, are clear aligners going to achieve the outcome the patient expects? Is it an extraction vs non-extraction case?
Consent – Where mutual understanding is reached, a two-way conversation is needed ensuring the patient has a good understanding of treatment options/limitations. The obligation is on the practitioner to ensure that the patient also understands their responsibilities (such as compliance, good oral hygiene, care of appliances, attendance as directed and so on).
Orthodontic treatment is often elective, expensive and relatively complex. Therefore, it is prudent to affirm any conversations with a written consent form which reiterates mutual understanding (signed before treatment commences) and / or a treatment letter setting out the practitioner’s findings and proposed care.
Financial consent – What is the cost, including any known additional costs such as retainers?
Who is responsible for payments? Treating minors can create the additional level of consent required when a child lives with one parent, and another parent is paying for the treatment. To avoid dispute, there needs to be full clarity about who is paying for what and who is entitled to discuss the child’s care, give consent on their behalf (or withdraw it) and access the records, prior to the commencement of treatment.
During treatment – Discussion of any concerns raised or unanticipated problems arising during treatment throughout, for example a tooth that is not moving as anticipated or standards of oral hygiene that may put the teeth at risk.
The practitioner should be working with the patient to address these concerns wherever possible, in an open and transparent manner.
If a tooth is not moving or is going dark, it may be in the patient’s interest to have another opinion such as from an endodontist. This may be a difficult conversation, especially if additional costs are going to be incurred.
If there are difficulties finding a mutually agreeable resolution, there may be a need to reconsider merits of proceeding. For example, if a patient is not compliant with oral hygiene measures and is at risk of causing permanent damage such as marking around brackets or caries, it may be in the patient’s best interests for the treatment to pause or cease.
Finish – At end of the planned course of care, was there a satisfactory outcome/an outcome within of treatment? This links back to options chosen and mutual understanding of limitations (consent) at the start.
Dispute about this is very common in surgical cases, where patients may have chosen a non-surgical compromised approach only to be unhappy with the outcome at the end of treatment – everyone needs to be on the same page from the start.
Burnout – Sometimes patients/families are tired and burned out with treatment and want to finish/ deband early – are they ceasing in full awareness of any compromises to the mutually agreed outcome at the start? For example, if there is still misalignment or bite discrepancies, is everyone aware and accepting of compromises before a deband?
Consent at end of treatment – This should be a reiteration of conversations had at the start – such as need for retainers, ongoing compliance, any further potential costs (for example in case of continued lost or broken retainers) and spelling out what could happen in case of non-compliance (such as relapse and future need for partial/complete course of treatment again at the patient’s expense).
In summary, if we consider orthodontic care as a journey that a practitioner and patient travel on together, it is best practice to ensure that everyone is on the same page on what the journey looks like, including the end point or destination, before the journey starts. Once travelling, any unexpected roadblocks or diversions should be flagged and discussed. At the journey’s end, the practitioner needs to ensure that the patient is ‘dropped off safely’ at their destination and any ongoing mutual obligations are discussed and understood.
References available on request.