I don’t think that I was taught orthodontics very well at an undergraduate level. That is to say, I think our lecturers scared us off it, telling us that it was best left to ‘the experts’, and so I didn't leave dental school feeling in any way confident to treat orthodontic patients.
I found it frustrating when I graduated to have a whole element of dentistry closed off to me, and so I sought to learn about it from as many credible sources as I could. I attended CPD, lots of it, for both long and short courses, including the best known of these long courses and honestly, all the courses were great, and I took something really valuable from each of them.
I chose my few first cases carefully, under the mentorship of the course coordinators, and took steady steps into providing some treatments. I selected a 14 year old girl who had a narrow upper jaw with a high arched palate and associated crowding of both her upper and lower teeth with impacted upper canines. She didn’t like her appearance as she had a depressed profile and described herself as ‘my upper and lower jaws are backwards compared to my forehead’. This was well within my remit and I knew we could get a really great outcome.
On this basis, I was excited to take this case on, and devised a couple of plans to present to the family; including the possible extraction of some teeth and the placement of fixed braces or alternatively proceeding by “slow expansion” to develop her upper arch. The family did not want extractions, and chose instead to have expansion, but, over time, the patient became more and more tired of orthodontic treatment and ultimately she burnt out. We discontinued the treatment at an agreed compromised but aesthetically pleasing place and although I was disappointed we didn't get to the end, I felt we were all satisfied and on the same page.
18 months later, the patient returned, still unhappy with the way she looked in profile, and wanting to pick up where we left off. I felt she was more emotionally mature and ready to commit, and so we proceeded with a twin block appliance, which was appropriate at this time.
Treatment progressed, but as her end of school formal loomed ever closer, the patient and her family pushed harder and harder for the treatment to be over. Eventually, I agreed to discontinue the appliances and issue retainers for short term wear to prevent relapse, so we could start again after the formal and finish her treatment for good. The family were thrilled and I polished her teeth for the photos and awaited their return. She never came back.
In fact, the next time I heard from the family was by a written complaint, saying that the work I had done was shoddy and needed to be redone and they wanted a full refund….but hang on – we weren't finished with treatment yet! Did they forget this? And, they said I had left her teeth in the wrong place and they wanted me to pay for her treatment to be redone with a proper orthodontist.
I was confident to fight this. I was armed with my knowledge of the treatment and the journey we had been on, and I had signed consent forms from the patient at every physical treatment stage and really good clinical analysis and treatment planning. But there was something I didn’t have. Everyday clinical records. Records of the conversations we had. Records of when I told her how long the treatment would take. Records of me telling her that repeated treatments (on/off of braces) could lead to jiggling forces which could shorten her roots and/or devitalise her teeth (her roots were already blunting and this was ‘my fault’ too) and records of the conversation where we discussed that the retainers were placed to let her have appliance free formal photos, NOT signifying the end of treatment.
I was shocked. I knew I was right. I had done the right treatment, despite the indifferent compliance of the patient, and I had tried to help them out. But I couldn’t prove it. I had done so much for the family, really bent over backwards for them, and a complaint was a poor thanks in my book. I was devastated.
The dentolegal adviser's perspective
Dr Annalene Weston, Brisbane office
Dr S learnt a very painful but invaluable lesson in this matter – if you didn't write it down, it didn't happen. The treatment provided by Dr S was appropriate, well planned and executed to a high standard. The main challenge here was the patient’s perception – like many orthodontic patients she wanted her treatment to be fast, cheap, invisible and pain free with no compromises, and getting a patient whose expectations are skewed like this to engage in the reality of orthodontic treatment is always hard, and sometimes impossible.
Dr S was very keen to defend what he considered to be a point of principal. Dr S did have good treatment to stand on and we assisted him in this defence. We did however ensure that he knew where his vulnerabilities lay and the likely consequences for him if these vulnerabilities came into play. Once the deficiencies in his record keeping came to light, the family engaged the services of a lawyer to fight him, not on clinical grounds, but legal grounds. At this point Dr S took the pragmatic view that his reputation and registration were worth far more than the satisfaction of standing his ground, and we therefore assisted him through a settlement negotiation process.
This matter resolved as well as it could under the circumstances as, once lawyers become involved, a clinical case is bumped into a different arena with completely different rules and the best treatment in the world becomes indefensible in the absence of solid and meaningful clinical records.
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