Dr Richard Hartley, Dentolegal Consultant at Dental Protection, looks at the considerations for any practitioner who might undertake short-term orthodontics.
Short-term orthodontics (STO) is becoming increasingly popular with adult patients, driven by factors such as social media and advertising. Where once adults were reluctant to embark on a course of orthodontic treatment, STO, particularly using aligners can offer a more aesthetic treatment option than conventional fixed orthodontics, with the promise that it can be completed in a relatively short period of time, and with the added convenience of treatment being provided by a general dental practitioner (GDP).
Dentists are of course keen to satisfy this demand from patients, although there are a number of factors to take into account when contemplating offering a course of STO, and there are potential difficulties for a GDP in providing treatment for which they have no formal specialist orthodontic training which they need to be live to before embarking on patient care.
These can include:
- Poor case selection can occur as a result of a lack of detailed knowledge, on how the particular systems work, and their limitations. This can be an issue when training has been undertaken in only one STO system, and that training may be limited, sometimes comprising only one day. The providers of the training will naturally want to extol the virtues of that particular system, and may underestimate their limitations; in addition, there may be other systems that would be better suited to a particular clinical scenario, but which the dentist will have no knowledge of, having not been exposed to that modality through their training.
- Orthodontic assessment and diagnosis. STO, despite the commercial aspects and promise of a swift outcome, is still orthodontic treatment, and as such a full orthodontic assessment and diagnosis should be undertaken at the outset. Often in cases Dental Protection assists with, there is very limited documentation of the orthodontic assessment, leading to difficulties in defending the actions taken, and treatment provided. It is easy for an expert appointed to review the treatment provided to identify early short comings, and how they flowed on to a poor outcome for the patient.
- Treatment planning and the ability to envisage the end result and any potential future problems, such as achieving a stable end point. Further, if the treatment does not go as anticipated, the practitioner may not have other treatment modalities better suited to achieve the desired outcome, such as fixed appliances at their fingertips.
- The consent process, which should include offering alternative treatment options, for example, referral to an orthodontist specialist. While often discussed, this is rarely documented, again, making the practitioner and easy target for a critical third party.
- Failure to identify and then manage patient expectations. The type of patient who may be seeking a cosmetic form of treatment such as STO may have high expectations, that are difficult to manage. These patients often present as a new patient drawn to your practice because you offer STO. This means that you have not had the opportunity to build up a professional relationship beforehand, as you have with your regular patients. This can lead to issues surrounding compliance, as you have no prior knowledge of the patient’s motivation, attitude to treatment, and attendance pattern. Given that STO and subsequent retention require significant compliance this lack of prior knowledge can lead to problems.
- Retention: in the rush to embark on STO treatment, patients can underestimate the retention process, leading to a nasty surprise for them at treatment end.
Many of the cases Dental Protection are asked to assist with, are difficult to defend due to vulnerabilities relating to one or more of the factors outlined above, with the most common issues relating to consent and retention. By way of resolution, patients will often seek financial recompense as STO involves a significant financial outlay, so that they can embark on a further corrective course of orthodontics. This can bring further issues such as; the risk of root resorption from repeated tooth movement, and further financial, and time commitment for the patient.
The best protection we can give ourselves, and our patients as GDPs, is to take the time to recognise when patients are not suitable for STO, including when their treatment needs are beyond our clinical capability to avoid getting into difficulty. Whilst STO can be a great practice take care not to embark on treatment that may be beyond your knowledge and skills, or on a patient you can never please.