How to avoid the dento-legal dangers of short-term orthodontics

Sep 26, 2022

Dental patients wanting to straighten their teeth are increasingly choosing short-term orthodontics (STO) to improve their smile. The appeal is that STO usually means using braces or clear aligners to straighten the front 6 or 8 teeth within 4–9 months, in a process considerably less invasive and time-consuming than conventional orthodontic treatment.  

Suitably trained general dental practitioners (GDPs) can provide STO but they need to know the limitations and risks involved. Unfortunately, litigation resulting from STO procedures has increased in recent years. However, GDPs can reduce the risks by staying within the scope of their skills and experience, managing patient expectations, and practising in accordance with guidance from the General Dental Council (GDC).  

Short-term orthodontics: not a ‘quick fix’ for all 

STO can produce satisfying results for certain patients who wish only to align their front teeth, but it is necessary to consider the pros and cons of the different options available, enabling patients to make an informed choice. A wide variety of STO systems are available to suit a range of budgets and treatment scenarios, so dentists need to understand their patients’ wishes and be able to advise them on the most suitable treatments to meet their individual needs.  

Full assessment of a patient’s oral health and dental structures is a fundamental part of treatment planning for STO. Not all issues can be fixed by STO and for some patients, especially those with complex problems, conventional orthodontic treatment will be a more appropriate solution in the long term. Used inappropriately, STO risks creating worse problems that need further costly and time-consuming treatment.  

The importance of managing patient expectations and enabling informed consent 

Patient demand for cosmetic STO may sometimes be based on unrealistic expectations, driven by societal pressures, social media hype and misleading advertising. This makes it especially important for GDPs to communicate directly and effectively with patients to fully engage them, manage their expectations and obtain valid informed consent before and throughout treatment.  

The GDC sets out the full requirements for obtaining valid informed consent, key points including: 

• Obtain valid consent before starting treatment, explaining all the relevant options and the possible costs.  

• Although a signature is important, it is the discussions with the patient that determine whether consent is valid. 
• Make sure that patients (or their representatives) understand the decisions they are being asked to make, and document this. Provide sufficient information in a format that they can understand and consider whether the patient is able to make decisions about their care.  
• Make sure that the patient’s consent remains valid at each stage of investigation or treatment. The consent process should be part of ongoing communication with the patient. Document specific consent for the procedure during each appointment and for any changes to the planned procedure.  
• Consent can be withdrawn at any time; in this case, ensure patients understand the risks or consequences and that they are responsible for any resulting problems. 

GDPs providing STO need to make sure that patients understand the limitations of treatment and accept their own role in the treatment contract to gain the best outcomes and avoid damage to their dentition; for example, the need for good oral hygiene, regular attendance at appointments, and requirement for life-long use of retainers to prevent relapse. 

Patients should be aware that:  

• Teeth will not move rapidly, due to the need for remodelling of supporting tissues. The speed depends on biological factors and may vary from the manufacturer’s claims.  
• Orthodontic treatment is associated with a risk of adverse effects and complications, including periodontal damage, pain, root resorption, tooth devitalization, temporomandibular disorder, caries, speech problems and enamel damage.  
• Underlying oral health conditions may impact on the overall success of alignment. 

At the American Association of Orthodontists 2017 Annual Session, Dr Laurance Jerrold, a specialist in dental risk-management education, presented template forms containing a comprehensive list of considerations for obtaining informed consent; although developed for a US audience, UK GDPs may also find this a useful resource for further reading. 

Dento-legal concerns with direct-to-consumer short-term orthodontics 

As patient demand has grown, some companies have started to provide direct-to-consumer treatments, so-called ‘DIY orthodontics’. Patients often consider using such services because they offer attractive prices without the need for multiple dental appointments.  

Dentists may be asked to confirm suitability of a patient for direct-to-consumer treatment, sometimes remotely. However, to reduce the risk of dento-legal issues, it is wise for dentists to avoid commenting on the specific STO appliance; instead, they could explain to the patient why it is important to discuss the treatment options and potential risks with a qualified, registered dental practitioner. 

Dentists have a responsibility to adhere to the GDC’s guidance and Standards for the Dental Team. In May 2021, the GDC issued an updated statement on direct-to-consumer orthodontics. Crucially, this makes it clear that: 

• Such services can only be performed by GDC-registered dentists and dental care professionals.  

• Full assessment of the patient’s oral health is needed to form clinical judgements about any proposed orthodontic treatments. “At present, there is no effective substitute for a physical, clinical examination as the foundation for that assessment.”  
• The responsibility for a clinical judgement lies with the prescribing dentist. 

The GDC also provides the following resources: 

• Information for dental professionals to support professional judgement. 
• Information for patients to support informed decision making about treatment. 

• Direct-to-consumer orthodontics – social media toolkit. 

Indemnify against risk in STO 

The GDC states: “Dental professionals also need to ensure that they are appropriately indemnified. Those who do not comply with the Standards for the Dental Team, indemnity requirements and authoritative clinical guidance put patient safety, and their registration, at risk.”  

GDPs can minimise the risk of problems if they perform STO within the scope of their own expertise and obtain valid informed consent, discussing with the patient all the treatment options, including referral to an orthodontist, as well as the risks, limitations and a realistic timeframe.  

As always, treating dentists should keep detailed patient records and note the reasons for any deviation from established practice and guidance. In the event of litigation, this documentation can provide evidence of informed consent and appropriate management of treatment. 

Please contact Dental Defence Society for expert advice if you face a complaint or claim or if you have any questions about indemnity requirements for STO.