From Volume 12, Issue 2, April 2019 | Pages 46-52
Those practising orthodontics frequently face ethical dilemmas. This article seeks to explore dilemmas, which the authors consider arise often in the field of orthodontics. The emphasis is on best practice, evidence-based practice and prioritizing patients' interests.
As with any area of dentistry or medicine, those practising orthodontics can frequently be confronted by ethical dilemmas. The elective nature of much orthodontic treatment increases the occurrence of these ethical conundrums. This article seeks to explore dilemmas, which the authors consider arise often in the field of orthodontics. It is not intended to be a guidelines document on standards, but rather encourage thought and debate regarding everyday orthodontic decision-making. The emphasis is on best practice, placing patients' interests first and, where possible, to be evidence-based. Each dilemma is investigated separately and an opinion is then offered. The layout has been chosen to allow the reader to scan though the paper finding some dilemmas that are interesting or useful and provides a structured way of approaching them.
| 1. Dilemma: Whether to use established orthodontic treatments or new treatment options to correct a malocclusion? |
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| Fact: Modern orthodontic appliances such as clear aligners and systems claiming to reduce treatment times are increasingly being advertised and offered to patients. There has also been a resurgence of non-extraction treatment and use of arch expansion to align teeth. |
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Evidence and best practice: There is currently a strong push in academic circles for orthodontic practice to become more evidence-based and for research to be of a sufficiently high standard to improve this evidence base. Whilst there is good evidence to support certain specific treatments,1 there is not a sufficiently high quality research base for a Cochrane review to examine if one appliance is superior to another for correcting crowded teeth.2 |
| Opinion: The above lack of evidence would suggest that it is unwise for practitioners to promote new appliances and techniques when the research supporting their superiority is not robust. The use of specific orthodontic appliance systems, which suggest by their name that treatment can be accomplished within a ‘shorter timeframe’, is not supported by evidence. |
| 2. Dilemma: Should all patients seeking aligner treatment or short-term orthodontic treatments from general dentists be offered a referral to a specialist orthodontist? |
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| Fact: Many general dental practitioners provide orthodontic treatment to patients, solely using an aligner system or a range of fixed orthodontic appliances. |
| Evidence and best practice: There is evidence that the quality of orthodontic treatment undertaken by specialist orthodontists is superior to that of general dentists in terms of treatment outcome.6 A Dental Protection study found 20% of new orthodontic claims cases in the UK in 2010 involved aligner treatment and general practitioners accounted for 80−90% of all aligner complaints and claims.7 Whilst there is an increasing amount of literature showing the value of aligner systems,8,9 short training courses for dentists undertaking aligner and other ’limited treatment objectives’ systems are unregulated, and have extremely variable mentoring.10 |
| Opinion: As with any area of dentistry, clinicians should operate within their ‘area of competence’. Where treatment can be provided to a patient by a suitably competent general dentist, this would seem entirely appropriate. As part of the consent process, the patient needs to be given all the relevant information about his/her treatment options. Where dentists do not use a range of orthodontic appliances or provide comprehensive treatment, they cannot obtain truly informed consent, therefore a referral to a specialist orthodontist must be an option offered to the patient. Compromise treatments may place teeth in an unstable position and thus necessitate permanent retention. Long-term reliance on retainers (fixed or removable) should be clearly explained to the patient as part of informed consent.11 Failure to advise patients of these long-term risks as part of the consent process is not ethical practice. |
| 3. Dilemma: Can ‘extraction cases’ be treated by expansion instead? |
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| Fact: Rates of orthodontic extractions have fluctuated over time12 and it is attractive to both patients and parents to avoid extractions if possible. |
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Evidence and best practice: It has been shown that expansion of the arch-form increases the tendency for relapse.13 Careful reflection is required as to where the teeth will be positioned following expansion, with thought given to the availability of alveolar bone to accommodate the roots of teeth, the gingival biotype and occlusion created following expansion. |
| Opinion: Whilst differences of opinion and treatment philosophy mean many ‘border-line cases’ may be treated with or without extractions, it is important to treatment plan for each and every case individually on its own merits. Due consideration should be given to the expected orthodontic outcome of incorporating extractions or not in a treatment plan, along with consideration of the potential side-effects and the final stability of the corrected malocclusion. Long-term retainer use must be explained to each patient and the implications of this retention consented to. It does not make any sense for a practitioner to describe themselves as a ‘non-extraction orthodontist’ or indeed an ‘extraction orthodontist’. |
| 4. Dilemma: What to do when a patient's request for treatment differs from what a clinician thinks is appropriate treatment? |
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| Fact: This dilemma most frequently arises with adult patients. The wish of the patient may be to have treatment only ‘to align my crooked front teeth’ or to have a single severely displaced tooth extracted. The clinician facing these demands may be concerned that providing treatment, in the first case, may worsen the malocclusion, or secondly might place the teeth in a potentially unstable position or leave visible interdental spaces (black triangles). |
| Evidence and best practice: Reasons for adult patients seeking treatment are varied but, perhaps unsurprisingly, the most common motive is to improve the appearance of their smile with straighter teeth.16 There is evidence to suggest that adult patients' self-esteem and oral health-related quality of life (OHRQoL) can be improved with orthodontic treatment.17 Patient personality can also have an impact on the likelihood of the patient being satisfied with his/her appearance at the end of treatment.18 It is vitally important to identify and respect a patient's wishes but also to manage unrealistic hopes and expectations correctly.19 |
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Opinion:
Taking time at the assessment stage, to ascertain not just the presenting complaint but a patient's expectation of what treatment may involve and what an outcome might be, is crucial. Communication is the key to avoiding treatment which is likely to result in a dissatisfied patient. Whilst patient autonomy is a pillar of medical ethics, a defence of ‘I gave the patient what they asked for’ is unlikely to be accepted should the patient be subsequently dissatisfied with the result of an ‘ill-advised’ treatment, and they pursue a complaint. |
| 5. Dilemma: Are compromise treatments plans appropriate? |
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| Fact: Limited objective treatment plans are often one of several options offered to patients seeking orthodontic treatment. |
| Evidence and best practice: There may be a divergence between a patient's perceived needs or desires and the orthodontist's problem list. In this situation, careful communication with the patient is essential.20 |
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Opinion:
Where a compromise plan is proposed as a valid treatment option it should be clearly described as such to the patient, with an explanation of what the proposed treatment will address and, more importantly, which problems it will not correct. The comprehensive treatment plan should also be presented and fully described with an explanation as to why the compromise plan is a reasonable alternative. If a clinician is unable to provide a full description of the comprehensive treatment, the patient must be given the option of a referral to a service where this will be available. |
| 6. Dilemma: To what extent should risks of treatment be discussed with a patient during the consent process? |
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| Fact: The law regarding informed consent has changed following the 2015 Montgomery Supreme Court decision.21 |
| Evidence and best practice: Prior to the Montgomery case, the ‘The Bolam Test’22 had been used to assess what a prudent clinician would be expected to explain to a patient in terms of information and risks for a procedure? The Bolam principle's answer to this dilemma is; ‘the information which a dentist in that situation would normally be expected to explain to a patient who needs that information’.23 The result of the Montgomery decision is that an individual patient must be given the information they would be reasonably expected to know before being able to choose to proceed with treatment or not. It should be noted that this court decision from a dental perspective enshrines into law what the General Dental Council standards24 state is good practice.23 |
| Opinion: When discussing risks of orthodontic treatment with a patient or parents, it is essential to advise of the risks of treatment relating to that individual patient. The elective nature of many orthodontic treatments places a greater onus on the practitioner to address the risks involved as it would be entirely understandable if a patient stated, following an adverse outcome, that they would have refused treatment had they known about the possibility of that outcome. |
| 7. Dilemma: Is it appropriate to commence orthodontic treatment in the mixed dentition if this will lead to longer treatment time? |
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| Fact: The timing of treatment is potentially influenced by a multitude of factors such as age at presentation, patient and parent demands, treatment philosophy of the clinician and commercial factors. |
| Evidence and best practice: In the case of functional appliance treatment, there is evidence to suggest shorter treatment times and better outcomes are obtained when treatment is commenced at age 12 compared to 8−9 years of age.25,26 Orthodontic anomalies, such as impeded eruption of permanent incisor teeth, warrant early intervention27 and for some skeletal anomalies, such as maxillary hypoplasia, early treatment to modify growth may be advantageous in the long-term.28 |
| Opinion: Treatment philosophy certainly is an important factor in deciding on a case-by-case basis when comprehensive orthodontic treatment should commence. Factors such as using leeway space and distalization of molar teeth may influence the decision to start treatment earlier. However, like all treatment decisions in dentistry, the patient's best interest should be the guiding factor. Starting treatment early in an NHS-funded setting with the primary objective of claiming additional units of activity or coercing a parent to start treatment early to guarantee that the treatment is not sought elsewhere, is obviously unethical. Early treatment must have clear objectives and demonstrable outcomes to the benefit of the patient. |
| 8. Dilemma: How should a clinician proceed in a situation when there is a disagreement between a child's and a parent's wish for treatment? |
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| Fact: A young person over 16 years of age can be presumed to have capacity to give consent and a child under 16 years may have capacity, depending on his/her maturity and level of understanding of the treatment involved.29 |
| Evidence and best practice: Qualitative research has shown that young patients and their parents have broadly similar expectations of orthodontic treatment, although some differences have been identified, with parents having a more realistic expectation of the time involved in treatment and children having a better appreciation of the restrictions treatment may place on their diet. It is suggested that children also have less expectation that orthodontic treatment will improve non-dental factors such as speech and facial appearance.30 The Fraser Guidelines set out the legal position for young people under the age of 16 to consent for treatment without the involvement of a parent.23 |
| Opinion: Fortunately, due to the elective nature of our treatments, dentists and orthodontists are rarely in a position where providing treatment without the agreement of a young patient is considered. As success of orthodontic treatment is dependent on compliance and attendance at appointments, it is always the ‘ideal’ that both patient and parent agree with a proposed plan. Where agreement between the patient and parent does not exist, it is appropriate to allow time for discussion at home followed by a review appointment for further discussion. Ultimately, a child's decision to refuse orthodontic treatment must be respected. Where young people wish to avail themselves of treatment, considered by a clinician to be in their best interest, in the absence of parental consent, it may be appropriate to provide this treatment, having carefully considered factors such as if the child is Gillick competent31 and ability to attend appointments. |
| 9. Dilemma: Does a patient need to be informed if the wrong tooth has been extracted following a referral to a GDP or oral surgeon, even if a satisfactory orthodontic result can still be achieved? |
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| Fact: Mistakes do happen due to either unclear or incorrect prescription of orthodontic extractions or operator error at the time of exodontia. |
| Evidence and best practice: Clear written prescription of the teeth for extraction in words as well as recognized dental notation should always be provided in a referral. A copy of a radiograph with the teeth for extraction clearly marked is a useful adjunct for the sake of clarity, especially in cases where supplemental teeth exist or where a primary tooth and its permanent successor are both erupted and present in the mouth. There is a professional32 and statutory33 duty of candour to inform patients of any mistakes which have caused harm. Advice should be sought from the professional indemnifier and, in an NHS trust setting, the event should be recorded on the incident reporting system (eg Datix). |
| Opinion: It is vital to document the events and advise the patient of what has happened. If the situation allows, it is reasonable to reassure the patient that the treatment plan can be altered to achieve a good orthodontic result but this cannot be a substitute for openness and honesty with a patient in this unfortunate situation. |
| 10. Dilemma: What is an acceptable end-point for completing active orthodontic treatment? |
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| Fact: An acceptable end-point to active treatment will depend on the complexity of the case, the original objectives and the patient aspirations. |
| Evidence and best practice: Validated and well established indices, such as the Peer Assessment Rating (PAR)34 and the Index of Complexity, Outcome and Need (ICON)35 are available to score a malocclusion quantitatively before and after treatment. The degree of improvement can also be established. |
| Opinion: Though the above indices do not take account of facial considerations or iatrogenic effects of treatment, they can readily be applied to well fabricated and correctly trimmed orthodontic models. From a patient's point of view, the result will be judged against his/her expectations and it should be borne in mind that these expectations are dynamic as they may change during the course of treatment. It is the responsibility of every treating clinician to ensure that the patient has a stable and functional occlusion at the end of treatment and the means to maintain the result long-term. |
| 11. Dilemma: What is an acceptable treatment time for completing active orthodontic treatment? |
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| Fact: Duration of orthodontic treatment depends on the complexity of the case and the treatment goals. Treatment, which persists longer than a patient expects or longer than estimated by the clinician at the outset, is likely to lead to patient dissatisfaction. |
| Evidence and best practice: There is no agreement in the literature about the length of an average course of treatment. Depending on the cohort of patients, actual mean treatment times quoted vary from 13 months36 to 29 months.37 Factors shown to increase treatment time include; impacted canine teeth, the number of teeth extracted as part of treatment, starting treatment early for correction of Class II division 1 malocclusions and the number of operators involved in treatment.26 Longer treatment times may be associated with greater iatrogenic effects, such as root resorption38 and decalcification.39 |
| Opinion: Acceptable treatment time is individual to each case. It is important from the outset that patients have a clear understanding of the expected duration of their treatment. They need to be informed about the risk that treatment may take significantly longer than ideal if appointments are not kept and breakages occur. When treatment progression is slow for any reason it needs to be identified early and addressed. This is especially important if slow treatment relates to an unrealistic treatment objective. If this is the case, a review of the plan is indicated and referral for advice may be appropriate. |
| 12. Dilemma: What to say to patients seeking a second opinion, with concerns about the orthodontic treatment they are receiving elsewhere. |
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| Fact: Patients who are unsure or unhappy with how their treatment is progressing may seek a second opinion from another dentist or orthodontist. |
| Evidence and best practice: Guidance on second opinions is available from defence organizations.40 The opinion should be factual rather than subjective and it is unethical to criticize another professional wantonly. It is also imperative, once a patient is accepted for such an assessment, that the information given to the patient at the consultation is in the patient's best interest. |
| Opinion: A second opinion is best given by a specialist. Great care should be taken when providing a second opinion that it is given in a thoughtful way and respects all parties. Blame is rarely helpful. |
| 13. Dilemma: When should treatment of a non-compliant patient be ceased? |
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| Fact: It is not uncommon for some patients to miss or cancel appointments regularly, not follow instructions such as elastic wear, break their appliances frequently or fail to maintain an agreed level of exemplary oral hygiene. |
| Evidence and best practice: Regular appointment keeping, satisfactory oral hygiene, a diet suitably low in sugar and good co-operation are all key factors in ensuring a successful outcome from a sound treatment plan. If any of these are lacking, serious consideration needs to be given to whether ending active treatment early is in the patient's best interest. |
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Opinion:
Good compliance and co-operation starts before treatment commences. It goes without saying that a patient who cannot or will not maintain satisfactory oral hygiene, diet control and keep appointments is unlikely to do so once treatment starts. Good records, demonstrating suitability for orthodontic treatment, prior to that treatment starting, are essential and more so when unsuitable candidates transform themselves into appropriate patients for appliance treatment. |
| 14. Dilemma: How much information should be given to patients about root resorption caused by their orthodontic treatment? |
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| Fact: Severe root resorption may become apparent during, or towards the end of, orthodontic appliance treatment. In some instances, this resorption may be identified long after completion of treatment, either by radiographic investigation of teeth with increased mobility or as an incidental radiographic finding. |
| Evidence and best practice: Some level of root resorption secondary to orthodontic tooth movement is probably inevitable. Careful history (both dental and family), assessment and radiographic examination prior to treatment can help identify some of the patients at an increased risk of severe root resorption.41,42 Consideration of the magnitude and type of the planned tooth movements can also predict, to some extent, if an increased amount of resorption is likely. However, resorption can be very unpredictable.42 |
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Opinion:
Informed consent is a key starting point to handle this potential event before it occurs. As this complication can affect any patient being treated with orthodontic appliances, all patients need to be advised of the risk of resorption. Patients with short roots, previous root resorption, a family history of orthodontically induced inflammatory root resorption and narrow roots, along with teeth planned for large movements, need to be especially forewarned about this risk. Only then can the patient make an informed decision that the benefits of treatment outweigh the risk of severe root resorption. For high risk patients, it is good practice to plan radiographs at a set time during treatment (eg after initial alignment or six to nine months into treatment). If significant resorption is identified, a re-evaluation of the treatment objectives needs to be undertaken. |
| 15. Dilemma: In the case of multidisciplinary treatments, what should be done if a practitioner is not satisfied with the treatment provided by another specialist? |
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| Fact: Orthodontic treatment plays a central role in cases such as joint orthodontic-restorative, periodontal-orthodontic, cleft and orthognathic treatments. There will invariably be situations where the result of a component of the joint care falls short of the expected outcome. |
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Evidence and best practice: Ideally, cases involving a multidisciplinary approach, in particular complex treatments, should be planned in a joint clinic. This allows for shared decision-making and identification of realistic plans. This avoids a specialist asking another practitioner to attempt to achieve impossible objectives. |
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Opinion:
A good working relationship between specialist practitioners is vital to the planning and execution of joint plans. Blame again is rarely helpful but a professional relationship needs to allow for candid discussion about the outcome of individual components of a joint treatment. Where colleagues frequently cannot agree on plans or have divergent views of outcomes, consideration needs to be given to the fact that patients' best interests may not be served by a continuation of these colleagues treating patients together. |
| 16. Dilemma: Who is responsible for retention once a treatment is complete and what should be done in cases where a patient is dissatisfied by relapse of their malocclusion? |
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| Fact: Retention regimens will vary from case to case. Significant relapse can occur due to an inherently unstable final occlusion, broken retainers or poor retainer compliance. Slight relapse over time as the final occlusion settles may be inevitable. |
| Evidence and best practice: Retention is an integral part of an orthodontic plan and needs to be consented for before appliance treatment commences. Patients need to be made aware that, in most cases, retention is long-term and slight settling and shifting of teeth, even with good retainer wear, can be expected. If a plan is likely to result in an inherently unstable result, the patient needs to be aware of the additional risk of rapid relapse and the need for an enhanced retention regimen, which they may find inconvenient.43 The period of supervised retention, for example up to one year after debond, needs to be communicated to the patient before treatment. Patients also need to be aware that retainers will need to be replaced in the future after discharge and they would normally be liable for the cost. Good documentation of the long-term retention plan is important. A copy of the long-term retainer advice, signed by the patient, is a useful record. |
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Opinion:
Dissatisfaction is more likely to arise where a patient is not fully aware of the risk of relapse or that their end-treatment tooth positions may be inherently unstable. If the retention plan is treated as an afterthought following active orthodontic treatment, the likelihood of dissatisfaction is increased considerably. |
| 17. Dilemma: Where is the line between legitimate and unethical advertising of orthodontic services? |
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| Fact: Orthodontists and dentists in practice advertise their services to patients using both traditional advertising media and, more recently, social media. Patients, as consumers, will base their decision to seek treatment and where to access their treatment on perceptions they form from advertising. |
| Evidence and best practice: Guidelines, both statutory and professional, for advertising dental and orthodontic services have been issued by the General Dental Council44 and the British Orthodontic Society,45 respectively. It is important that these guidelines are adhered to when advertising services. It is outside the scope of this article to list these guidelines in full and both are essential reading for anyone practising orthodontics. Of particular importance regarding advertised information; it should be current and accurate, claims should be backed up by facts, and statements likely to create unjustified expectation in the minds of patients should be avoided. Websites should be kept up to date and include the GDC numbers of the clinicians providing the service. Stating or implying that a practitioner is a specialist orthodontist is prohibited unless his/her name is included on the GDC Specialist List of Orthodontists.44 |
| Opinion: Many patients will understandably find the distinction unclear between ‘specialist dentists’ and dentists with a ‘special interest in’ an area of dentistry. If this confusion is exploited, merely to sell services, a practitioner could leave themselves open to an accusation of unethical conduct. |
