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Aligning your ethics

13 November 2019

Mr H attended a routine examination appointment and expressed dissatisfaction about the position of his upper anterior incisors and the prominent position of his upper canines. The dentist advised the patient they could provide treatment through a clear aligner system and offered an immediate orthodontic assessment. Mr H agreed and they went on to discuss potential orthodontic treatment within that same appointment.

Mr H informed the dentist that he had received previous orthodontic treatment five years ago, but had never been completely satisfied with the final aesthetic result. The dentist observed Mr H’s upper incisors were mildly retroclined, which exaggerated the buccal position of the upper left and right canines.

The dentist informed Mr H that he was a suitable case for treatment with clear aligners and provided an estimate of costs. Mr H was very pleased with the proposal and immediately agreed to go ahead with the proposed plan, with an expectation that the treatment would take between 6-12 months to complete.

Treatment commenced and Mr H and the dentist were happy with the progress made during the first six months. However, as the dentist moved into the final set of aligners, Mr H began to express dissatisfaction with the final position of the canines which, in his opinion, were still too prominent. The dentist informed Mr H that the position of his teeth was now anatomically correct and felt no further treatment was needed. Mr H remained dissatisfied and insisted that further treatment be carried out.

Against the dentist’s better judgement, he agreed to provide further treatment with the intention of moving the upper anterior incisors to a pronounced buccal position to help disguise the prominent canines. This refinement phase continued for a further five months, at which point Mr H complained of discomfort and pain from the upper incisors, and he was now concerned that these teeth felt ‘slightly loose’.

The dentist noted the mobility and referred Mr H to a specialist periodontist as he thought Mr H may have a periodontal problem. Mr H demanded a referral to a specialist orthodontist to assess the situation. He expressed his concern about the outcome, his disappointment with the aesthetic result, and the discomfort he was now experiencing. He made it clear that he would seek legal advice should his concerns not be dealt with promptly.

The dentist contacted Dental Protection and requested our advice. Dental Protection reviewed all the treatment records and advised a way forward in order to resolve Mr H’s concerns. Unfortunately, the treatment records suggested that the orthodontic assessment was inadequate and incomplete. The absence of a lateral cephalometric radiograph, lack of occlusal assessment, discussion of all relevant treatment options based on the orthodontic diagnosis, along with their advantages and disadvantages, not only compromised the care of the patient but also failed to demonstrate valid consent had been obtained.

The dentist’s position was further weakened by the report from the periodontist who noted the poor position of the upper incisor roots, which had resulted in dehiscence and fenestration through the buccal cortical plate, which was likely to have occurred during the refinement phase.

Dental Protection informed the dentist of his vulnerabilities and requested a specialist orthodontic report, along with a remedial treatment plan. The dentist acknowledged he had not given sufficient attention to the orthodontic assessment. He also accepted his role in causing the complications now evident as a result of agreeing to provide further treatment against his better judgement.

The dentist offered a refund of the failed orthodontic treatment and Dental Protection confirmed that the cost of the remedial orthodontic treatment phase would be paid on behalf of the member.

Mr H continued treatment with the specialist orthodontist and was ultimately pleased with the final aesthetic result, which involved fixed upper braces and a further nine months of treatment. Mr H was therefore willing to accept the dentist’s offer of a refund and reimbursement of remedial treatment costs, and the case was resolved.

Learning points

  • Ensure you provide a full orthodontic assessment, including exposure of appropriate radiographs and occlusal assessment, and offer appropriate treatment options, along with the risks and benefits of each.
  • Ensure the patient is provided with adequate information and time to fully consider the treatment options – take the opportunity to rebook the patient when necessary.
  • Beware of a demanding patient with high aesthetic needs – do not be pushed into providing treatment you do not feel is clinically appropriate or potentially damaging to the patient.
  • Always provide an option of referral to a specialist colleague at the outset or in a timely manner, should the treatment not be progressing as you or the patient had intended or as expected.
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These case studies are based on real events and provided here as guidance. They do not constitute legal advice but are published to help members better understand how they might deal with certain situations. This is just one of the many benefits dental members enjoy as part of their subscription. 
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