Portal de Periódicos da CAPES

Risk management strategies in orthodontics. Part 1: Clinical considerations

2015; Elsevier BV; Volume: 148; Issue: 2 Linguagem: Inglês

10.1016/j.ajodo.2015.05.011

1097-6752

Ahmad Abdelkarim, Laurance Jerrold,

Orthodontics and Dentofacial Orthopedics

Orthodontic therapy uses safe procedures resulting in significant functional and esthetic benefits with relatively few risks. Nevertheless, in an increasingly litigious society, one that raises an autonomous patient's expectations while reducing tolerance for doctor errors, it is prudent to implement simple risk management strategies for the dual purposes of rendering an enhanced level of treatment and minimizing exposure to potential legal action. The strategies and opinions expressed do not necessarily represent the opinions of the American Journal of Orthodontics and Dentofacial Orthopedics, the American Association of Orthodontists, the American Board of Orthodontics, or the College of Diplomates of the American Board of Orthodontics. Orthodontic records include comprehensive medical, dental, and social histories; extraoral frontal and lateral photographs; an appropriate means of memorializing the intra-arch and interarch occlusal relationship and the status of the hard and soft tissue structures by photographs, scans, or models of the dentition; and appropriate radiographs to visualize the dentoalveolar structures and the dentofacial and skeletal relationships as specific cases dictate. It is especially important to take panoramic or intraoral radiographs about 9 months after initiating treatment to monitor for root resorption and to continue to do so at least once annually. Your staff needs to appreciate the importance of quality records acquisition. Poor-quality records have often been the basis of litigation. Intraoral photography is an excellent means of documenting poor clinical response or cooperation. Cone-beam computed tomography is beneficial in certain patients for 3-dimensional evaluations of impacted teeth, temporomandibular joints, pharyngeal airway, and other structures. Because adults have different physiologic factors than do adolescents, such as periodontal condition and healing capacity, their treatment should take these and other clinical factors into greater consideration. Because of the greater propensity for interdisciplinary treatment with adults, additional records are often required, including periodontal charting, periapical radiographs, temporomandibular joint examinations, and detailed medical and dental histories. Since periodontal disease is episodic, a history of past periodontal treatment is vital. Patients with previous periodontal disease may be at greater risk of developing periodontal breakdown during orthodontic treatment.1Mathews D.P. Kokich V.G. Managing treatment for the orthodontic patient with periodontal problems.Semin Orthod. 1997; 3: 21-38Abstract Full Text PDF PubMed Scopus (74) Google Scholar All diagnostic records require evaluation—at least qualitative if not quantitative assessment. Whether examining an intraoral photograph or a cone-beam computed tomography scan, it is not difficult or unusual to detect clinical abnormalities or pathology. Be sure to document that the patient was informed about the condition as well as any referrals made. Orthodontists frequently request clearance from the general dentist before starting treatment. Clearance by the general dentist, pediatric dentist, or periodontist is important not only for the patient's benefit but also for risk management purposes. Regardless of any clearance obtained, the orthodontist is still responsible for the treatment rendered, since he or she is the treating practitioner. Relying without question on another doctor's clearance is inappropriate unless you concur with his or her findings. The orthodontist should continue to monitor the oral cavity during treatment and strongly encourage all patients to visit their dentists for regular "cleaning and cavity checks" before, during, and after treatment. Obtaining the patient's informed consent before any treatment is essential to ensure his or her understanding of the proposed treatment, agreement to proceed with the treatment despite its limitations and inherent risks, and understanding of all viable alternative options, including no treatment, and the associated risks and benefits associated with each.2Jerrold L. The role of expert witnesses in claims for lack of informed consent.Am J Orthod Dentofacial Orthop. 2006; 130: 687-688Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar All risks and limitations discussed should be documented. Atypical or unusual cases often require additional express consent. For example, cases involving impacted teeth require the patient's understanding of the risks of ankyloses, damage to adjacent teeth, devitalization, prolonged treatment, and compromised final positioning of the teeth or surrounding hard and soft tissue support.3Rinchuse D.J. Jerrold L. Rinchuse D.J. Orthodontic informed consent for impacted teeth.Am J Orthod Dentofacial Orthop. 2007; 132: 103-104Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Specific consents should be obtained when dealing with impacted teeth, periodontal diseases, mini-implants, bisphosphonates, and laser use. Documentation that the patient's consent was obtained takes many forms, ranging from no documentation to videotaping the consult, a practice that requires the patient's awareness of being taped in some states. Consider acquiring additional progress records to support any changes in the initial treatment plan. Making promises can lead to claims of false advertising. Orthodontic treatment benefits are usually dramatic; however, there are nearly always limitations. Normalization as opposed to perfection is often a better stated approach, and total correction should never be guaranteed. Since nothing lasts forever, the treatment results may not be stable in the long run, even if a retainer is worn. These limitations should be discussed, perhaps at greater length than the treatment's benefits. A posttreatment consultation outlining not only what was achieved but also what was not is a viable risk management tool and should be documented and preserved. Patients who dictate treatment plans are common. Not only are orthodontists liable for any treatment they render, but their performance is optimized when they pursue treatments and techniques that they have already mastered. Although patient autonomy is highly valued in contemporary bioethics, the patient is usually best served when the doctor and the patient collaborate in formulating the treatment plan.4Greco P.M. A case for collaboration.Am J Orthod Dentofacial Orthop. 2015; 147: 15Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar Patients have autonomy, but so do doctors, and they are not required to render treatment that they are not comfortable providing or believe is not in the patient's best interest. The most frequent situation in which an orthodontic laboratory plans treatment occurs with clear aligner therapy. No matter how large or influential the laboratory is, it is the doctor's responsibility to acquire full records, make a diagnosis, formulate a treatment plan, and undertake treatment. The doctor should determine from the beginning whether the patient qualifies for aligner therapy, since he or she will shoulder most of the potential for liability. The bottom line is to allow the patient to proceed with aligner therapy after fully understanding its benefits and limitations. Even though few patients are truly orthognathic candidates, this option should be offered and discussed, if viable, even if the patient or parents are likely to decline it. Patients can become furious if they think that the orthodontist carried out treatment resulting in a less than desirable result when another option may have more fulfilled their expectations. If orthognathic surgery is pursued, let the surgeon formulate the treatment plan while you render prescription orthodontics, as opposed to participating in the surgical treatment planning. Adults, especially those above age 30 years, have different physiologic factors and expectations than do adolescent patients. They also have more detailed medical and dental histories. For example, approximately half of the population above 30 in the United States has periodontitis.5Albandar J.M. Underestimation of periodontitis in NHANES surveys.J Periodontol. 2011; 82: 337-341Crossref PubMed Scopus (123) Google Scholar It is wise to be realistic with these patients, especially if they have specific expectations and chief complaints that can be addressed via limited or partial treatment. If you are uncomfortable rendering partial treatment, do not agree to do so. Remember that the doctor-patient relationship is bilateral and consensual, and both parties have the autonomy not to participate. Whereas typical patients should be treated typically, treating an atypical or unusual patient in a typical fashion may occasionally render disastrous results. For example, a case involving severely ectopic canines and no crowding or spaces in both arches may qualify for canine extractions rather than first premolar extractions. Another example is the extraction of the maxillary second molars before beginning first molar distalization in a Class II malocclusion. These treatment plans do not deviate from standards of care. They are viable treatment alternatives with their own sets of benefits, risks, limitations, and compromises. Early orthodontic treatment (ie, phase 1) is often beneficial for certain patients and need not involve comprehensive appliances or treatment. Phase 1 treatment aimed at correcting a specific problem can be a better approach than the "sit-and-wait" strategy. Examples lending themselves to phase 1 intervention are correcting a crossbite resulting in a functional shift, eliminating certain habits, or sequential extractions to precipitate eruption of specific teeth. Correction of an anterior crossbite can prevent periodontal breakdown on a mandibular incisor and improve dentofacial esthetics.6Rinchuse D.J. Kandasamy S. Myths of orthodontic gnathology.Am J Orthod Dentofacial Orthop. 2009; 136: 322-330Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar Whereas these patients benefit from early treatment, it is unethical to render it for the sole purpose of getting the patient into the practice before someone else starts treatment. Modern evidence does not support a correlation between orthodontic treatment and temporomandibular disorder (TMD).6Rinchuse D.J. Kandasamy S. Myths of orthodontic gnathology.Am J Orthod Dentofacial Orthop. 2009; 136: 322-330Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar Unfortunately, some patients and practitioners still believe that orthodontic treatment may cause TMD. Existing TMD symptoms or parafunctional habits should be documented before any treatment. Failure to do so allows patients to associate their treatment with the onset of TMD. Patients should be made aware that orthodontic treatment may or may not eliminate any TMD symptoms, and even if they are ameliorated, they can return later. Treat TMD symptoms as interdisciplinary and make appropriate referrals to those with training in orofacial pain management. It is essential to monitor patients' hygiene during each visit. Bleeding gingivae are an alarming indicator of poor oral hygiene.7Sanders N.L. Evidence-based care in orthodontics and periodontics: a review of the literature.J Am Dent Assoc. 1999; 130: 521-527Abstract Full Text PDF PubMed Scopus (53) Google Scholar Aiming for optimal oral hygiene is an excellent strategy to minimize the risk of negative sequelae: a risk that must be thoroughly discussed with the patient and documented in the record. Applying fluoride varnishes throughout treatment coupled with oral hygiene instruction may minimize this risk. If significant noncompliance continues, it is often best to terminate treatment before the risk manifests itself. It is critical in these circumstances to avoid supervised or contributory neglect. Patients with poor oral hygiene, active periodontal disease, gingival bleeding on probing, deep pocketing, or tooth mobility are not good candidates for orthodontic treatment; their periodontal condition is often exacerbated by orthodontic treatment. It is important to identify patients at risk of developing periodontal disease before treatment.1Mathews D.P. Kokich V.G. Managing treatment for the orthodontic patient with periodontal problems.Semin Orthod. 1997; 3: 21-38Abstract Full Text PDF PubMed Scopus (74) Google Scholar It is also important to retain teeth within the genetically determined envelope of the alveolar process to prevent dehiscence and fenestration. If these manifestations occur, referral is mandatory. Bonding or debonding errors can cause permanent damage to the enamel, such as decalcifications, enamel cracks or fractures, and tooth discoloration. Enamel deformities can occur even with a safe bonding and debonding technique. Safe bonding practices such as avoiding prolonged enamel acid etching, using adhesives containing fluoride, removing excess adhesive around brackets, and using fluoride-releasing sealants may minimize these risks. Attempting to achieve maximum bonding strength may be antithetical to safe debonding. Debonding appliances and removal of the adhesive remnants should never be delegated to an assistant. Bonding tubes on molars mitigates most of the risks and negative side effects of bands, such as interproximal loss of attachment, greater plaque accumulation, and impeded patient ability for self-maintained oral health (eg, flossing).8Boyd R.L. Baumrind S. Periodontal considerations in the use of bonds or bands on molars in adolescents and adults.Angle Orthod. 1992; 62: 117-126PubMed Google Scholar Banding can be painful and has the risk of a band pusher or bite stick slipping injury. Because separation is required for banding, there are the side effects of pain and the potential for separators to become submerged into the gingiva.9Monini Ada C. Guimarães Mde S. Gandini Júnior L.G. Santos-Pinto L. Hebling J. Tooth separation: a risk-free procedure?.Am J Orthod Dentofacial Orthop. 2012; 142: 402-405Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Interproximal caries developing during treatment can be radiographically detected if tubes are present but may be masked if the patient has bands. One common reality in orthodontic practice is the ingestion and aspiration of objects. If ingested, bonded tubes are more likely to pass through the digestive system than bands. Because each tooth differs in size, position, and shape, there is no ideal orthodontic force. The most appropriate orthodontic force is light and continuous, thus minimizing the risk of iatrogenic injury. The latest evidence suggests that increased root resorption is associated with increased forces, and a pause in tooth movement could be beneficial in reducing root resorption, thus allowing resorbed cementum to heal.10Roscoe M.G. Meira J.B. Cattaneo P.M. Association of orthodontic force system and root resorption: a systematic review.Am J Orthod Dentofacial Orthop. 2015; 147: 610-626Abstract Full Text Full Text PDF PubMed Scopus (161) Google Scholar Whenever an invasive procedure that carries certain risks is avoided, these risks are eliminated. For example, cortocotomy surgery or temporary anchorage device placement can cause infection, bleeding, pain, or paresthesia. If orthodontic mechanotherapy can be initiated and treatment goals achieved without these procedures, it might be prudent to avoid them. Since orthodontic treatment is usually elective, it is counterintuitive to create an unnecessary risk with a significant potential for injury. Protecting a patient's eyes is a simple risk management strategy. Using protective eyewear protects the eyes not only from flying objects but also from slipping tools and caustic liquids. Curing-light eyewear that absorbs UVA and UVB radiation is the ideal form of protection during initial bonding and bonding of fixed retainers. It should be office policy for everyone to wear protective eyewear: doctors, staff, patients, and chairside guests. Even the most straightforward cases may not finish with good results. Aiming for perfection in orthodontic practice may be a poor strategy and often induces anxiety and unnecessarily prolonged treatment time. Aiming for "the best given the circumstances" and selecting the best time to end treatment are better risk management strategies. Some patients never achieve good results for multiple reasons, including poor compliance, unfavorable tooth or periodontal reactions, inadequate tooth-size proportions, and other highly complex factors. Patients need to be told and to understand that teeth are not embedded in cement but in bone, which continually remodels throughout life. For this reason, tooth movement after treatment need not be equated with relapse. Retention minimizes but cannot eliminate undesirable tooth movements. Every patient requires a unique form of retention, largely depending on initial presentation, results achieved, cooperation, age, growth pattern, and patient and clinician preferences. The aggressiveness of retention ranges from none (self-retention) to fixed retainers and surgical intervention. Fixed retainers are valuable from a stability perspective but can impede the patient's oral hygiene efforts; if they are loosened or their form is accidently changed, it can lead to rapid relapse. Taking quality and comprehensive records, clearing patients for treatment, obtaining appropriate informed consent, and using the Golden Rule are essential risk management strategies. Because limitations are inherent in some cases, it is essential to discuss treatment potentials in terms of improvement rather than correction. It is important to collaborate with the patient to meet his or her expectations and avoid circumstances that are antithetical to good risk management.