The Top Five Complaints Orthodontics

Before you start: if you are a GP dentist performing orthodontics, please ensure you have taken out the appropriate level of Professional Indemnity (PI) insurance cover for this area of your practice. Insurers may include this as an “add-on” to a standard dental policy meaning you will need to specify that you intend to engage in this area of practice.  If your PI policy does not cover orthodontics (or, if you neglect to take out cover for orthodontics as an additional defined procedure when this is available), then you could be putting yourself at considerable financial risk.   

What do patients complain about?  On reviewing the complaints data for 2022/23, it is evident that the area which attracts the highest volume of orthodontic complaints in SA is dissatisfaction with the treatment outcome.  The patient may say that the treatment did not meet their aesthetic expectations or that it took longer, was more difficult or more costly than expected.  Sometimes, the treatment outcome is pleasing but the patient experiences relapse. A confounding factor arises when the original treating clinician is unable to complete the course of therapy or the patient decides to consult another clinician.   When this occurs, a common trigger for a complaint is the introduction of unexpected or additional costs.

The most serious complaints in orthodontics (ie: where the penalties/outcomes for the clinician can be most significant) arise when the patient experiences an adverse outcome. These cases are often complex and can be the result of deficiencies in diagnosis (such as failure to recognise and treat complex underlying skeletal or growth anomalies) or where the patient suffers harm during the treatment (eg: TMJ dysfunction, root resorption or shortening, tooth devitalisation, periodontal breakdown).

As with all complaints, practitioner conduct can sometimes be the focus of the complainant.  Unique to orthodontics, is the complaint that the patient was not aware that the clinician they were consulting was not a specialist orthodontist (more on this below).

Getting started (TIPS on what to consider):  The Dental Board of Australia mandates that each practitioner must only perform those procedures in which they have undertaken sufficient education and training and in which they are competent (Dental Board of Australia - Scope of practice registration standard).  Each individual practitioner is responsible for self-assessing their own competencies. Immediately upon graduation, most dentists will have sufficient training to enable recognition of malocclusions suitable for referral to specialists.   Undergraduate training does not generally adequately equip new graduates to be competent in providing comprehensive orthodontic diagnosis or treatment.

How do you get started? If you want to provide orthodontic treatments for your patients, you will need to identify suitable courses for augmenting your clinical and diagnostic skillset. Some practitioners will elect to complete the further 3 years full-time study required to qualify as a specialist orthodontist. If you don’t intend to do this but would like to treat simple orthodontic cases, then you will need to identify suitable CPD courses to set you up with the diagnostic training you will need to recognise the cases suitable for your skillset and which will also equip you with the knowledge and ability to effectively treat these cases.  A good guide is to look for reputable CPD providers such as the Universities or Professional bodies (such as the ADA and affiliated societies) as these organisations do not have vested financial interests – ie: they are not attempting to promote a specific product or technique and can offer more balanced perspectives on the available alternatives. It can also be helpful to ask around – particularly seeking recommendations from experienced/knowledgeable colleagues, including specialist orthodontists, and those who have recently attended CPD courses.  

Please beware of marketing assurances that short courses held over a very short time (hours or days) will be all that you need.  It sounds self-evident, but many such courses will not provide sufficient training to enable you to start assessing and managing cases on your own, nor support you to recognise and manage complex situations and complications.  If you can work under the guidance of an experienced clinician/mentor or in collaboration with a specialist orthodontist, then this will assist you in identifying those cases which lie within your developing competency and also help you to recognise which cases should be referred.  Do not be convinced by marketing assurances that you can provide treatment according to the prescription or instruction of some remote practitioner (whom you have never met), or a company/ orthodontist claim of accepting liability for your patient’s clinical outcomes.   Particularly where these providers are located offshore, it will be YOU as the treating dentist (not the remote instructor) who is held responsible for treatment outcomes (and who would face the scrutiny of the regulator or be liable for civil penalties in a legal dispute).   Plaintiff law firms will seek to join the practice/business owner to a negligence claim so, if you are an independent contractor running your own business, make sure you have appropriate insurance cover.

What about the social six?

There has been growing interest in treatment that can be carried out for adults by correcting the aesthetics of the “social six” (upper incisors and canines). Often, the treatment plan includes other cosmetic procedures such as bonding, bleaching, veneers or crowns with the clear aim of enhancing the aesthetic outcome.  Risk is minimised if this type of treatment is carried out within the practitioner’s competency, where the patient is a fully-informed competent individual and where there has been a comprehensive pre-operative analysis including a diagnostic wax up (or similar representation of the expected treatment outcome) so that the patient can see what is possible and hence approve a realistic/achievable outcome. Many such cases are treated without issue and favourable results are achieved.  However, be aware that patients who aren’t satisfied may seek a second opinion and, if this occurs, it will be important that you fully considered (and are able to demonstrate) all available treatment options (including referral to a specialist) before any treatment began.

TIP: Upfront disclosures - Consider including a statement in your patient consent requiring the patient to acknowledge (by signing) that they are aware their treating clinician is not an orthodontist (if you are a GP dentist) and which also specifies they have been offered referral to a specialist. 

Make sure to include all the other alternatives, including no orthodontic treatment, which may be available to treat their presenting complaint as a list of options they have been offered (and rejected).  These acknowledgements by the patient are much more effective if they appear as stand-alone statements which are initialled/signed independently (rather than being part of the minutiae of a four-page document signed at the bottom of the last page).  

Don’t ignore the financial aspects:

One common area of complaint arises when patients are asked to pay more than expected – often because the treatment plan/provider changes.  When patients transfer from one clinician to another, it is important to facilitate the process by communicating with the patient/parent, organising referral in a timely manner, providing records and details of the treatment to assist the transition of care (eg: Invisalign transfer cases) and accounting for the financial aspects in a fair and prescribed way. This may mean returning payments received for treatment not yet completed (and, in turn, this may require a contribution from the practice as well as from the treating practitioner depending on practice payment structures). 

Tips to avoid problems:

Diagnosis, treatment planning, informed consent and record-keeping are key factors in providing best-practice patient care and are your best defence if/when a complaint arises:

• Be sure to treat only within your competence
• Perform a comprehensive examination and record all findings
• Record your diagnosis and the aims of treatment 
•  Seek input from others where necessary
• RECORD the expected treatment outcome
• Involve the patient – have they considered all the options and do they understand the treatment they are entering into – do they understand the expected end point and all costs (particularly if a multi-disciplinary approach is required).
• Ensure the patient understands that once active orthodontic treatment is completed, the process is not finished. Management of retention and retainers is indefinite and will be associated with further ongoing costs.

What to do if you receive a patient complaint:

If you receive a patient complaint or claim or have any queries relating to patient management, please don’t hesitate to contact the Branch Peer Advisor for confidential assistance and support.