How small a detail is too small for
informed consent with Orthodontics?
Every now and then I am reminded that patients may not
understand everything we do and why things we do may be necessary. This may be
something as simple as taking periodic radiographs to checking roots of teeth during
treatment to repositioning brackets in an attempt to level gingival margins or
even polishing/re-shaping edges of teeth for a better fit and a stronger edge
against future wear. I know that I certainly
can get into a pattern and just move forward with treatment without always
consulting with parents on what I feel are simple or insignificant (but
necessary) aspects of treatment with braces and ,to be honest, many times it is
not the parents bringing the kids in the first place. But alas, we as Orthodontists should never
underestimate the protective motherly oversight of a parent or the well-surfed
google experts that scour the Interweb for tidbits of information regarding braces
and Orthodontics. And the longer a
patient is in treatment, the more questions arise. When these questions do arise we need to
address them completely and promptly.
A gift from one
of my patients!
Keep in mind that anyone can find a story on braces causing
everything from rampant decay to periodontal disease even to circulatory
problems, allergies or even autism. It
always amazes me how much dis-information Orthodontists are up against with
every new year. Even our dental colleagues
may have incorrect positions on braces or biases against traditional braces simply
because they now offer aligner trays and think they are equivalent (which is
nonsense of course). So Orthodontists must
always try to explain treatment while dismissing the many urban myths about
braces before and throughout treatment.
So when is consent needed during treatment?
Orthodontists want you to be informed and aware of important
procedures and risks v. benefits of our treatments; we have state and national
meetings about consent, entire journal articles are focused on educating
Orthodontists as to the legalities of treating with parental permission and
choosing parental wishes even over better care in some cases. Orthodontists want
everyone to be on board with treatments and we want treatment to go smooth
without complications or mistrust. But
we also have been highly trained and we may gloss over more insignificant points
may be just too small a detail to keep repeating for everyone at every visit. After all, we cannot take 30 minutes to
discuss every bend or every spring at every visit or we would never be able to
finish. Expect your Orthodontist to
explain why teeth may be removed to gain space, why certain specialized appliances
may be used such a palatal expander or headgear, why braces may be preferred or
even required over other methods and when/why progress records will be taken
during and at the end of treatment.
Expect to hear about risks of tooth movement in general and specifically
related to you or your child, expect to hear of any possible options including
of no treatment is performed. Expect to
get consent for significant reshaping between teeth though simple polishing
should be expected if it will affect the occlusion of teeth or is needed to
level the teeth and gingival margins. Expect
to hear when there may be changes in your treatment plan, when compliance is
poor (including oral hygiene) or when important goals are net throughout
treatment.
“Orthodontists want you to be
informed and aware of important procedures and risks v. benefits of our treatments”
I personally start all treatment with a series of three
appointments: first as a complementary initial exam to see if treatment may be
warranted, second a full records appointment with a nominal fee to show
commitment to any treatment and third with a complementary but mandatory sit-down
consult to discuss records and any treatment plan including risks, procedures
and prognosis of treatment. Everyone
goes through this so there are fewer questions during treatment and so that
patients and parents have a chance to ask questions and discuss options. I give a written treatment plan and copies of
records to every patient and let them take home the information before starting
any treatment.
I know many offices have moved to a single initial
visit/consult/start on the same day but I always have felt it is better to sit
down and put everything in front of the patient so if there is an issue that arises,
the patient and/or parent knows we were expecting something or at least had performed
due diligence. This also educates the
patient on what is expected from them.
What you should allow your Orthodontist to do during treatment without
specific Consent:
Once you have understood the treatment plan and reviewed
records and consented to treatment, allow the Orthodontist to place the braces
and wires as he/she sees fit. Expect
there will be appointments where the wires will simply be tied tighter, changed
to larger or stronger wires and expect to hear things like power chains/counter
force wires/NiTi (titanium wires)/elastics prescribed and placed. These are basic to most cases and should not
require separate consent. Also, expect a
radiograph to be taken at 6 to 12 months into treatment to view root positions
and help guide the Orthodontist to a smooth and timely finish. If there is breakage expect the Orthodontist
to remove old brackets and polish teeth in preparation for a new bracket. If there are rough edges on teeth that affect
the occlusion, expect the Orthodontist may want to smooth those to prevent
breakage during and after Orthodontics; he/she may also need to adjust edges of
teeth where previous wear pattern have created irregular or asymmetric wear on
teeth that affects the gingival levels or may cause future unfavorable wear to
opposing teeth; remember (contrary to current aligner companies such as
Invisalign suggesting otherwise) the Orthodontist is primarily responsible in
providing ideal function above all.
With proper consent before treatment including time to
answer questions and discuss options, patients and parents will be more
trustful when we have taken a routine x-ray to check roots half-way through
treatment or that we have to polish/re-shape a tooth for a good fit or to
remove cement even though it may be in the written consent at the beginning of
treatment. We never want parents and/or
patients that are distrustful as this leads to a desire to wants written
instructions on everything we do and hovering parent that questions us at every
step. This kind of distrust can easily lead a discontinuation of treatment and
a transfer out of a practice under these conditions.
Braces have maintained a relatively consistent price over
the last 20 years (my fees have grown from @4500 to $6500 while crowns have
risen from $350 to $1200!) because of technologic advances in materials and
more efficient treatment protocols but if every patient was to question and resist
every aspect of treatment on every patient, we would likely have to double our
fees.
“… patients and Orthodontists
have to get on the same level of expectations with consent, with compliance and
ultimately with outcome of treatment.”
Both parents and patients must be taught that Orthodontics
is not just a series of plastic aligner trays as they may see advertised. And patients and Orthodontists have to get on
the same level of expectations with consent, with compliance and ultimately
with outcome of treatment. Orthodontics
is a dental specialty; it marries developmental biology, physiology, growth,
and experience with physics, biomaterials and art. It is terribly complex and
requires thought, preparation and modifications throughout treatment and it
cannot be completely explained at every step.
There may certainly be a gray area of consent v. efficiency and it is up
to the doctor and the patient/parent to define that line but I would ask parents
of young patients to find the professional you trust at the beginning, do your
research and get comfortable with your doctor …. then trust your Orthodontist
to do give you and/or your child the best care possible. No Orthodontist wants to harm anyone or
damage anyone’s teeth/joints and all of us have very extensive training; trust
that your Orthodontist knows what he/she is doing and why they may recommend certain
procedures for a better smile and bite and you will have a better experience
and likely a better result.
I would ask parents of young patients
to find the professional you trust at the beginning, do your research and get
comfortable with your doctor …. then trust your Orthodontist to do what is good
for the patient and teeth.
If you have questions or comments concerning this or any
orthodontic question, please feel free to make a complimentary new-patient
appointment at either my Steiner Ranch location or my North-central Austin
location on West 35th street and MoPac.
Dr. James R. Waters is
a 1996 graduate from UTHSC Dental School in San Antonio, 1997 graduate of
Advanced Dentistry from the UNMC in Nebraska and the 2001 Valedictorian
graduate from the prestigious Saint Louis University Orthodontic Program
receiving the J.P. Marshall award for clinical excellence in 2001. He holds a Bachelor’s Degree in Science,
Doctorate in Dental Surgery, a post-doctorate certificate in Advanced
Dentistry, post-doctorate Degree in Orthodontics & Dentofacial Orthopedics
and a Master of Science Degree in Orthodontics and is a Diplomate of the
American Board of Orthodontics. Dr.
Waters and his wife of 20 years live in Austin, TX with their 4 children where
he has a thriving, multi-faceted Specialist practice with locations in Steiner
Ranch and North-Central Austin. You can
learn more about Dr. Waters at BracesAustin.com.
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