by Laurance Jerrold, DDS, JD
There are essentially three categories of communications that are used in an orthodontic office: intraoffice, interoffice, and extraoffice. Intraoffice pertains to all internal forms and communication tools that one uses to enhance procedures and office efficiency. Extraoffice entails all communications between the office and patients, third-party payors, administrative agencies, etc. Interoffice communications deals with all correspondence with other offices having to do with the interdisciplinary treatment of your patients. Occasionally, some of the communications will overlap categories due to the complexities of private practice today. This article will discuss the risk-management principles behind various interoffice communications.
The First Letter
The first interoffice communication generated is after the patient has called your practice and has had an initial screening. It begins with thanking the dentist for referring the patient. If a GP was not the referral source, it allows you to notify him or her that you have seen the patient and either
- treatment is presently recommended;
- the patient’s problem is best treated via recall observation; or
- the patient has decided not to take advantage, for whatever reason, of the benefits of treatment.
This is important because often the orthodontist will be able to defend against a claim of misdiagnosis, failure to recommend treatment when it was indicated, or neglecting to treat if treatment was indicated if, in reality, it was the patient who refused to accept therapy. It will also indicate whether the patient is foregoing recommended therapy at this point in time (see Form A). Both of these scenarios commonly occur in root resorption cases secondary to ectopically erupting canines.
This is to acknowledge, with thanks, your referral of (Name) to our office. It is a pleasure to assist you in (Name’s) overall dental treatment.
Insert appropriate paragraph 1–4 below:
If Option 1: An appointment has been made for (Name) and complete records will be taken. We will furnish you with a synopsis and orthodontic treatment plan as soon as possible.
If Options 2 or 4: When (Name) is ready to initiate active orthodontic therapy, we will furnish you with a synopsis and treatment plan at that time.
Thanks again for your expression of confidence and support. We will do our utmost to have this referral reflect favorably upon your choice of an orthodontic specialist.
- We fully agree that now is an opportune time to begin orthodontic therapy. Please let us know your usual office procedure with regard to periodic examination and prophylaxis. We shall be happy to cooperate with you in every possible way.
- We have recommended that (Name) be kept under periodic observation until such time as treatment is indicated. We sincerely feel that postponing treatment at this time is the procedure of choice in this type of malocclusion. Due to your early diagnosis and referral, (Name) will benefit from our being able to monitor his/her growth and development and institute appropriate timely therapy.
- After preliminary examination, we feel that the risk/benefit ratio in this particular case is such that orthodontic treatment is unwarranted. We will be happy to discuss this matter with you at your convenience.
- We fully agree that now is an opportune time to begin orthodontic therapy.
- (Name) is considering undergoing treatment.
- However, due to undisclosed reasons, (Name) wishes to delay the start of treatment.
- However, due to financial considerations, (Name) wishes to delay the start of treatment.
- (Name) has indicated, however, that he/she wishes to forego the benefit of orthodontic therapy.
- Ideal treatment for this patient may involve orthodontics and (state the form of interdisciplinary therapy). The patient is considering this option.
Form A provides the appropriate communication for all options relating to the patient’s initial screening visit.
You may also encounter a patient who does not have a general dentist, and you now have the opportunity to refer them to one. In this case, you should send your standard introduction letter to three local referrers, allowing the patient to choose between them. By reciprocating to three different referrers for all of the referrals they have previously given you, you are killing three birds with one stone.
Once you have determined a treatment plan, most offices send out synopsis letters. Virtually every practice-management software package has one. Many offices send out two: one to the patient and one to the GP. The synopsis letter is both a great practice-management and a great risk-management tool. The problem comes when these letters are used incorrectly. The most common error is when the synopsis letter to the patient paints a “sunny, blue skies” kind of picture, while the letter to the dentist depicts a “storm clouds on the horizon” image. When the case goes south and the parties are in court, it is difficult to reconcile the discrepancies between the letters. Usually the result is that the patient claims that vital information was withheld from him or her, resulting in a claim for lack of informed consent—an easily reached conclusion based on the orthodontist’s reluctance to note in the patient’s letter any of the potential negative sequelae or problems that were prominently mentioned in the letter to the GP.
Medical History Letters
When treatment is about to begin, there are a number of form letters that the orthodontist needs to keep in his communications arsenal. Besides being great risk-management tools, they have a strong practice-management component as well. The first one is a general letter to the patient’s physician inquiring into whether or not the patient has any medical conditions that might impact receiving orthodontic therapy (see Form B).
I would appreciate your letting me know if there is any information in your records regarding diagnosis or treatment for any of the following disorders:
- hereditary or genetic diseases
- infectious diseases
- bone metabolism
Trusting I have the pleasure of hearing from you soon, I am
PS Attached for your convenience is a handy reference sticker with our phone number which can easily be applied to (Name)’s chart. Thank you,
I authorize the release of the above requested medical information pertaining to myself/my child as requested by Dr______________________
While all of this information was available from the patient’s medical history, it is a belt and suspenders type of risk-management position one should adopt. In addition to its low cost and high return ratio, it carries the potential to become another referral source as well.
The next letter is a specific one relating to patients who present with a positive history of cardiopathy that may require antibiotic prophylaxis. It asks the cardiologist about the nature of the disease, whether or not SBE prophylaxis is recommended, and, if so, what regimen to follow (See Form C). If you send out this letter or make a phone call to elicit the same information, make sure you get a response. There is nothing worse than knowing you need to make a referral, making it, and than ignoring the response or not following up on not having received one.
(Name) is under our care for orthodontic therapy. Our medical history reveals that (Name) has (fill in choices from 1–5 below).
Please advise us as to the following:
- The nature of the cardiac problem.
- Whether or not you recommend prophylactic antibiotic coverage for SBE.
- If so, should we follow the American Heart Association regimen or one of your own?
Thank you for your prompt reply.
I authorize the release of the above requested medical information pertaining to myself/my child as requested by Dr __________________________________.
- heart murmur;
- rheumatic fever;
- prosthetic joint replacement;
- mitral valve prolapse; or
- unspecified cardiomyopathy.
The next letter is for the ENT physician, allergist, and/or pediatrician. It alerts the medical specialist to your clinical and radiographic findings and inquires into whether or not there is a history of, or treatment for, nasorespiratory embarrassment, eg, tonsils, adenoids, turbinates, or sleep apnea; and if there is, to treat appropriately and keep you in the information loop (see Form D).
(Name) has been evaluated by our office for orthodontic therapy. Our examination revealed the presence of or history of:
[ ] steep mandibular plane
[ ] open bite tendency
[ ] excessive lower face height
[ ] mouth breathing
[ ] radiographic large adenoidal tissue mass w/ nasopharyngeal obstruction
[ ] deviated septum
[ ] engorged turbinates
[ ] history of allergic rhinitis
[ ] high narrow palatal vault
[ ] obstructive sleep apnea
[ ] antral polyps
[ ] ___________________________
As you are aware, upper airway obstruction in the formative years can significantly affect one’s dentofacial growth and development. Untreated obstructions can also seriously affect the stability of any orthodontic treatment rendered. Please examine (Name) regarding the above noted factors and evaluate him/her for any necessary treatment.
If you wish to discuss (Name)’s case with us, please feel free to call.
Forms B through D should be used as often as possible for the patient’s protection, your protection, and to keep your name in the forefront of the local medical community.
Once you know who the patient’s other treating dental health care providers are, you must have a stable of letters for various clinical situations that unfold. The requisite communiquÉs include, at a minimum, a periodontal evaluation letter (E), a caries exam memo (F), and a surgical procedure prescription form (G).
Please evaluate the need for:
[ ] oral hygiene instruction
[ ] prophylaxis
[ ] deep scaling & curettage
[ ] other
as (Name)’s present oral environment is not compatible with orthodontic treatment.
In addition, please evaluate the following areas/tooth numbers for the following procedures in conjunction with (Name)’s treatment.
Area/tooth Number(s): ______________________________________________
[ ] frenectomy
[ ] supercrestal circumferential fiberotomy
[ ] free gingival graft
[ ] gingivectomy
[ ] gingivoplasty
[ ] apically repositioned graft
[ ] crown lengthening
[ ] ______________________________
If you feel that more extensive treatment or therapy is indicated, please inform our office so that we may aid in any way possible and also allow us to reschedule the patient accordingly.
Please examine the following surfaces for caries:
Some of these surfaces may be small; however, these teeth will have orthodontic appliances placed on them, and therefore we leave it to your judgment as to whether you wish to restore them at this time. This exam was done [ ] with [ ] without the benefit of radiographs.
In conjunction with (Name)’s orthodontic therapy, please:
[ ] extract
[ ] expose
[ ] consult on
[ ] provide the following:
From a risk-management perspective, the only real requirement is to maintain a copy of every communiquÉ in some fashion in the patient’s record.
Poor Cooperation Letters
There are times when all is not going as planned. For these instances, you must have two poor cooperation letters. The first is to notify the patient or parent that without the necessary level of cooperation on their part, treatment results may be compromised. In the event that lack of cooperation gets so bad, you will want to notify the patient that unless the tenor of the relationship changes, they may be subject to early dismissal. At some point, you will have to notify the general dentist that patient cooperation is lacking and request that they intercede if at all possible (See Form H). They too need to know that treatment may be compromised and that there is the possibility that treatment may be discontinued early because of the poor risk/benefit ratio of continuing to treat a noncooperative patient.
As you know, we are currently providing orthodontic care for (Name). Even though we are giving our closest attention to (Name)’s case, his/her response to treatment has been slower than normally expected. The problems to date appear to have been * (insert from categories below).
We will continue with (Name)’s treatment as long as it is clinically feasible to do so in order to achieve the best possible clinical result. However, due to the situation as previously described, some limitations or compromises regarding our initial treatment goals may occur, including early termination of treatment.
If you have any questions, please call us. You may wish to recall (Name) at this time to examine him/her and reinforce to him/her and his/her parents, the positive benefits of orthodontic therapy and the cooperation needed to achieve these ends. We have discussed this with (Name)’s parents so they are aware of the situation.
- not wearing appliances as instructed
- not complying with oral hygiene instructions
- not keeping appointments
- poor skeletal growth/response
- slow dental developmemt
- other: ___________________
These types of letters have saved many an orthodontist from malpractice suits or have helped to minimize jury awards. The caveat is that after a certain number of these have been sent, you must act affirmatively regarding patient dismissal. To do otherwise is to engage in what is known as supervised neglect.
You also need to have four completion letters, two for Phase I treatment and two for comprehensive treatment; in each case, one goes to the patient/parent and one goes to the GP. Again they need to say essentially the same thing. The Phase I letter (see Form I) alerts both the GP and the patient that a) the first phase of treatment has been completed, the treatment goals were or were not met, and the patient will be kept under observation for the need for Phase II. Everyone needs to be on the same page that phase one was only that and was not comprehensive therapy.
(Name) has recently completed his/her first phase of orthodontic treatment. Through early intervention we have sought to maximize (Name)’s potential for proper dental and orofacial development.
(Name) has been placed under periodic recall observation. He/she will be monitored at regular intervals to determine if a second phase of treatment is indicated and, if so, the extent and timing of such intervention.
We have recommended that (Name) call your office to make an appointment for routine dental care. If you have any questions regarding (Name)’s treatment to date, specific future concerns, or the philosophy of interceptive orthodontics in general, please feel free to call.
The second set of letters is again for both parties and again outlines what was and was not accomplished, what type of retention is required, and whether or not long-term observation is necessary and for how long (see Form J). It should also indicate who is responsible for monitoring any fixed retention employed.
Just a note to let you know that (Name) has recently completed active orthodontic treatment. We were happy we could provide (Name) with all of the benefits that orthodontics has to offer. Every effort has been made to address our original treatment goals regarding the establishment of good function, optimum aesthetics, and maximum stability. (Name) will now enter the retention phase of therapy. Once the period of retention observation has expired, we expect that you will continue to monitor the patient at your normal recall appointments.
(Name) has been told to call your office to make an appointment for routine dental care. Should you have any questions concerning (Name)’s treatment or orthodontics in general, please feel free to call us.
While there are certainly other interoffice communications that occur on a daily basis, the ones previously referred to have important risk-management components. Properly structured and worded letters can mollify the daily stresses associated with practicing in an increasingly litigious atmosphere. Having your practice-management advisor or legal counsel review your communication forms is an important component of prudent practice.
Laurance Jerrold, DDS, JD, is the dean and program director of postgraduate orthodontics at Jacksonville University School of Orthodontics and is a nationally recognized dental risk-management educator. He can be reached at