Martin Foster discusses the medicolegal risks associated with orthodontics.
Although there has been a marked rise in mask-wearing across the world, the appetite for having a nice smile is unlikely to wear off anytime soon. We are all attracted to things which are easy on the eyes, so it is little wonder that so many patients will turn up in our surgeries wanting us to work some magic on them to enhance their appearance.
The profession has always been in the field of improving cosmetics and in recent times has witnessed the rise of what is essentially a mass market in adult orthodontics. This may be good news for those with cosmetically challenged smiles, but sometimes the magic does not deliver and dentists find themselves on the receiving end of complaints and claims from patients whose smiles are far from happy. So, what goes wrong?
There are recurring themes in orthodontic complaints, some more common than others.
A small proportion stem from patient dissatisfaction if the clinician refuses to provide treatment in the first place. There may be a barrier for the patient in understanding the reason for this decision. Careful communication is crucial to allow the patient to process information, which can prevent this kind of complaint.
The way the clinician processes information is also important. Cases arise where there have been failures to take account of factors such as missing or ectopic teeth, undiagnosed impactions, previously traumatised teeth and underlying anatomical and functional causes of occlusal derangement, which have not been identified accurately. Overlooking these will obviously make a successful outcome more difficult to achieve. Many issues can be avoided through accurate diagnosis and careful assessment.
Related to this is knowing the limitations of what is possible with any particular technique. Too often, issues arise when an approach is taken which is fundamentally unsuited to the situation. This can end up with both dentist and patient on a bumpy journey before arriving at a destination neither of them wanted. Being aware of what is achievable before setting off is vitally important.
Other obvious risk areas in orthodontics include resorption and loss of vitality. These are recognised complications but can come as unpleasant surprises to patients, who may then perceive these as evidence of fault. A failure to warn may be viewed as a breach of duty, so the possibility of these outcomes should be included in the consent process, along with an explanation of what may be involved in terms of further treatment – and costs – should these arise.
In moving teeth to their final position, the patient may have to go through an ‘ugly duckling’ stage. Looking worse than they did when they started is not high on the desirable expectation list of most patients, so it is sensible to ensure they understand the possibility of this phase before it happens. Instances frequently arise where a patient has fled, disappointed, mid-treatment before the dentist has been able to finish the case.
Similarly, patients vote with their feet when treatment takes longer than anticipated (or promised). To avoid these risks, take time to spell out what to expect before embarking. It makes sense to overstate the likely time frame as very few patients are disappointed when their treatment finishes ahead of schedule.
Once treatment is completed there are still hazards. Patients keen to get a result quickly may agree to a treatment plan with limited aims and will be prepared to accept a compromised result when they start but by the end of treatment expectations may have grown. Patients may have a selective memory about having opted for a more economical option with its correspondingly more limited scope. To help prevent this it is good when presenting options to provide clear documentation of the choices available which sets out and explains the differences in result that these will achieve.
Once the teeth are in place it is good if they stay there. Not all patients comply with instructions on retainer wear, of course. Once again selective memory is evident when the patient returns complaining that their teeth have moved, wanting further treatment, a refund, or both.
You cannot make patients adhere to instructions but you can do yourself a favour by providing clear, written instructions on retainer wear, including the risks of non-compliance with advice and what to do if the retainer is lost or damaged. The patient must understand that they have a responsibility to act in accordance with advice to prevent relapse and that if further treatment is required to address this, it is likely to incur further costs. The teeth are straight; the advice should be too. Carefully record all of the advice, instructions and warnings given in your notes. One day you will be glad you did.