by Julian Perez, Vice President of Risk Management & Compliance at dentalcorp; Michelle Budd, DDS, Patient Safety Consultant at dentalcorp
With the rise of clear aligner therapy in dentistry, it has become increasingly common for general practitioners (GPs) to provide orthodontic services like Invisalign. Offering orthodontic services is a differentiating factor for general practitioners and can help set practices apart in today’s highly competitive market.
On the other hand, orthodontic care is a specialization that in very few ways resembles conservative general dentistry. In fact, in some dental schools, students will have received virtually zero orthodontic experience by the time they graduate. Provision of orthodontic services may present a significant degree of risk for poor treatment outcomes and subsequent complaints and/or malpractice lawsuits. Clinically speaking, clear aligner therapy generally tends to start off without any issues. Complications most commonly present themselves at the back end of care, after the expected completion date of treatment.
Below are 10 risk management tips for general practitioners when offering—or looking to offer—orthodontic services. Simply knowing about the risks in advance can help practices prevent many of them from getting out of hand, all while keeping patients happy.
1. Know when to refer patients: Some orthodontic treatment is complex. In an ideal world, GPs providing clear aligner therapy would have an orthodontist consultant who can advise them on which cases are simple and which are better left to a specialist. When surgery is required, GPs just starting out would be well advised to refer the patient out to specialists for the orthodontic component. Additionally, when treatment is not proceeding as expected, it’s important to get a second opinion before the patient suffers irreversible damage. For example, when TMD flares up mid orthodontic treatment or if recession or root resorption advances faster than expected, referrals should be offered immediately. Be sure you are competent to make the diagnosis and carry out the treatment plan. When in doubt, consult with a specialist or refer it out.
2. Manage patient expectations on length of treatment: This is especially true when it comes to estimating how long the patient will be in active orthodontic treatment. Each patient is unique – so, it is wise not to rely on a stock/standard estimate. Minor delay is usually forgiven; however, each patient has a breaking point after which they become frustrated and lose trust in the dentist. Avoid this risk is by telling patients upfront that, in some cases, orthodontics can take longer than the estimated treatment length.
3. Manage patient expectations on the final treatment outcome: When the treatment is purely esthetic, patients and dentists may disagree on what the ideal final outcome looks like. Again, dentists should carefully explain to patients beforehand that orthodontics can improve their smile, but it cannot provide a perfect smile in every case. Managing expectations is key. Using photography before and during treatment is one way to ground expectations and guide conversations. Asking the patient ahead of time what their idea of success looks like and managing expectations about whether that can be achieved is a valuable strategy.
4. Avoid charging the patient more than the original estimate: When care drags on, dentists begin to incur expenses without generating any new revenue. After a few refinements, the case becomes less and less profitable. At this point, some dentists decide to start charging the patient, even if the original amount was paid in full. When this occurs, patients can understandably become disgruntled. If your practice is considering charging the patient more than the originally agreed upon amount, proceed with caution. If willful non-compliance is at the root of the prolonged treatment plan, charging might be reasonable. If the original treatment plan was itself unrealistic, extending goodwill to the patient might be advantageous.
5. Do not allow decay to occur during orthodontic: This is even more important with fixed bracket and wire braces; however, it also applies to clear aligner therapy. The patient who sees a dentist (even if it’s just for orthodontics) every six weeks will not understand how cavities were allowed to grow at the same time. Oral health and hygiene must be addressed during orthodontics. Consider taking x-rays to check for decay as well as root resorption.
6. Be mindful of divorce proceedings with parents of minor patients: When a marriage breaks down, parents sometimes stop cooperating. This applies to all dental care, but orthodontics is a long-term treatment that cannot necessarily be conveniently discontinued midstream. Dentists should be careful not to get caught in the middle of contentious divorce proceedings or custody disputes. Choosing sides is rarely wise, but parents may pressure dentists to do just that. As a health care professional, your fiduciary duty is to the patient. Be aware as well that if you have recorded the parents’ financial information in the patient’s chart, one or both of the parents may not want you to share that information with the other. This can lead to a minefield of issues when requests for access to records occur.
7. See patient’s entire course of treatment through: If a patient’s care switches halfway through the orthodontic treatment, the risk of dissatisfaction increases immensely. Not all dentists and patients are compatible when it comes to orthodontic treatment planning. Additionally, dentists often don’t want to be on the hook for the treatment plan of another dentist, especially during signs of trouble. High turnover of associates will significantly increase this risk. Treatment should not be planned unless there is ongoing, full discussion and consultation with the patient, and you have a stable and supportive practice environment.
8. Educate patients on IPR prior to treatment: Some dentists can be fairly lax when it comes to inter-proximal reduction (IPR) – when IPR is required. On the other hand, patients can be quite shocked and upset to see their teeth whittled down. If patients haven’t been properly educated, you cannot blame them.
9. Maintain adequate patient records: At all times, dentists should maintain adequate records of diagnosis, chief complaint, informed consent and progress notes, and ensure that all of these are in place at the practice where the patient is treated. This is required by provincial regulations as well as health information legislation. If a regulatory body requests the patient’s orthodontic records five years after completion of treatment, they must be available at the practice(s) where the patient received treatment. Complications can arise if, for example, an associate left the practice without first transferring the 3D models, etc. from the cloud-based software used by the clear aligner company to the practice’s local records management system.
10. Obtain informed consent: As with any treatment, obtaining documented informed consent requires ongoing discussion of all treatment options and their relative costs and benefits. Given the length and complexity of orthodontic treatment, a written diagnosis and treatment plan (with options and recommendations) along with the written record of the patient’s consent to the agreed to treatment is imperative. In your informed consent process, be sure the patient is aware that you are providing services as a GP rather than a specialist orthodontist.
In many cases, orthodontic treatment begins while children are “incapable minors,” meaning that parents or legal guardians are making all health care related decisions on the children’s behalves. As children grow and mature, however, they will become competent decision makers. This means that at some point, the consent that was obtained from the mother or father will no longer be valid. In most of Canada, there’s no age of consent for health care decisions. Dentists and their teams must know their patients so that they can determine whether it is the child’s or the parent’s consent that is required. If there is any ambiguity, it is recommended that, when possible, clinicians obtain consent from both parents and child.
As previously published in Oral Health Office. This can also be found online here.
About the Authors
Julian Perez is the Vice President of Compliance & Risk Management at dentalcorp and is responsible for the development, implementation, and oversight of company-wide standards, programs, and systems to support practices in the delivery of optimal patient care. Julian has a robust legal background having worked for a Wall Street law firm in Manhattan as well as a professional liability program providing malpractice defense to over 10,000 dentists. Julian holds a bachelor’s degree from Yale University and a juris doctorate from Columbia University’s School of Law.
Dr. Michelle Budd works with dentalcorp’s Compliance & Risk Management team as a Patient Safety Consultant. She graduated from Western University with a Doctor of Dental Surgery degree. While running a busy dental practice, she also earned a Master of Public Health degree. Michelle has been a dental consultant for several insurance companies and government agencies and has travelled throughout Canada to help dental practices achieve and maintain professional compliance.