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Direct-to-consumer orthodontics: understanding the risks

15 June 2021

Dr Yvonne Shaw, Dental Underwriting Policy Lead at Dental Protection, considers some of the risks of patients pursuing direct-to-consumer dental care

The growing popularity of adult orthodontic treatment has seen increased activity from companies offering orthodontics services directly to patients. 

A recent survey by the British Orthodontic Society (BOS) identified that 80% of orthodontists had seen an increase in adult patients seeking orthodontic treatment.1  The restrictions on practice arising from the COVID-19 pandemic, coupled with patients having to engage with remote dental care and advice, may lead to more patients seeing orthodontic treatment through a direct-to-consumer (DTC) approach as an attractive option.  

We have considered some of the risks the dental team probably need to consider that may flow from patients pursuing DTC dental care.

Acting in the patient’s best interests

Central to the dentolegal questions that members ask about is the risk of harm to a patient.  Concerns range from a patient not understanding the implications or limitations of treatment but also the risks relating to the treatment itself, such as:

- Progression of pre-existing dental conditions such as periodontal disease or caries
- Root resorption
- Exacerbation or development of TMJD
- Adverse tooth movement such as creation of anterior or lateral open bites and changes to occlusion

Of course, all the above risks can equally apply to any course of orthodontic treatment and these types of complications form the basis of some of the claims we deal with. However, the risk of a problem developing, or not being identified at the outset, is likely to be significantly increased if a patient has not had a full clinical examination prior to commencing treatment.  

The question we are often asked is what a clinician should do if they become aware a patient is, or is contemplating, undergoing treatment provided through a DTC site. Professionals recommend an initial face-to-face contact at the beginning of the patient consultation and it is therefore appropriate to make patients aware of the potential risks of proceeding with a course of treatment in the absence of this examination taking place. To assist in communicating the risks, members may find it helpful to direct patients to and search for “direct to consumer” – this is an Australian Society of Orthodontists page that details some of the risks involved with DTC treatment. 

Another consideration is that patients may fail to disclose they are, or have been, undergoing treatment with aligners obtained directly from a DTC site. This could impact upon the assessment of a dental problem or provision of dental care where tooth position may not be stable.  This may be an issue where patients have not attended for care during the COVID-19 pandemic but proceeded with orthodontic treatment in the interim. Dentists may therefore wish to consider asking specific questions to elicit whether a patient has had any form of dental treatment, including any ‘DIY’ approaches, as part of their assessment process.

Access to records

Another question that arises is how to respond to a request from a patient, or DTC orthodontic provider, to supply written confirmation that a patient is fit to proceed with orthodontic treatment. This is in effect asking a dentist to make a decision on whether or not a patient is suitable for treatment that the practitioner themselves will play no part in planning or delivering.

While a patient may have attended recently for dental examinations, this does not equate to a patient being fit to proceed with a specific course of orthodontic treatment. It would not be appropriate for a clinician to comment on whether a patient is fit to proceed where they have no involvement in the clinical assessment, treatment planning or provision of that course of treatment.  In this scenario, it would be in the patient’s interests to advise that a clinical examination, with an appropriately trained orthodontic clinician, would be required to ensure all treatment options and specific risks are considered.

However, patients may instead request a copy of their records or provide authority for these to be disclosed to a third party. If the patient has made such a request, and provided a signed form of authority, then the disclosure of information should be dealt with in accordance with data protection legislation. If the records are to be disclosed with a view to dental treatment being provided elsewhere, one approach that could be considered would be to provide a courtesy call to the patient confirming receipt of the request thereby opening a discussion into what treatment the patient is seeking. A clear note of any discussion with the patient regarding what was advised should be recorded in the patient’s records.

Adequate and appropriate indemnity

All dental professionals must have appropriate insurance or indemnity in place to make sure that patients can claim compensation to which they are entitled. 

Registrants must therefore ensure they have adequate and appropriate indemnity arrangements in place if they are involved in the provision of DTC orthodontic treatment. Dental registrants working in this setting are therefore encouraged to speak to Dental Protection to ensure appropriate protection is in place for themselves and their patients. 

Clinicians working for DTC providers need to ensure they are not breaching any regulatory guidance. 

What to do if a patient returns

Sometimes a patient may return after having started or completed DTC orthodontic treatment. They may be disappointed with the results and ask the clinician to provide more treatment or ‘fix’ the unsatisfactory treatment. 

As with all patients, the clinician should treat them with ‘fresh eyes’ and complete their regular, thorough assessment of the patient. An appropriate assessment, diagnosis and detailed discussion with the patient about what they do not currently like about their teeth and what their expectations are will help the clinician in forming a treatment plan that will help overcome the patient’s concerns. Naturally, if the patient’s expectations are unrealistic or the clinician feels they cannot meet them, the patient can be informed of this and referred to another dentist.  

As with all dental treatment, the patient and clinician should have a discussion around the treatment options, possible treatment outcomes, risks and benefits of each of the options.  

Any members of Dental Protection affected by the issues outlined in this article should contact our dentolegal advice line on 1300 444 542 for further guidance and support.



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