by Laurance Jerrold, DDS, JD
Part 2: Walking the walk and talking the talk
The following is a good way to obtain informed consent. It involves sending a preliminary letter followed up by a conventional informed-consent form that is signed and kept with the chart. This is a good method for poor verbal communicators. You can also convert the form into a checklist that identifies factors to be discussed at the consultation visit. This method might be for better communicators, and requires that you memorialize the informed-consent discussion with your patient, in some fashion, in your patient’s record.
If you are like most orthodontists, when a new patient calls for an appointment, you send him or her a “Welcome to Our Office” packet. It probably includes a letter that thanks the patient for selecting your office and confirms the appointment time. It usually includes a brochure about you and your office, a map showing your location, and possibly a health questionnaire to be filled out in advance.
Let me suggest that you start obtaining informed consent before you even meet the patient. Along with the other data, use the following two letters: “Your Right to Know” and “Information Concerning Your Treatment.” These two communiquÉs set the stage for an interactive relationship between you and your patient. Send the following letter with your “Welcome to Our Office” packet of information.
Your Right to Know
It has been said that, “An informed consumer is our best customer.” This has never been more true than in the provision of health care services. What should you expect when you first visit an orthodontist? You should be told what the problem appears to be; what tests are necessary to properly diagnose the problem and formulate a treatment plan; and, in the case of a child, whether now is the appropriate time to begin therapy or whether it is best to wait until a future date to initiate treatment. Let’s look at these individually.
When a patient either desires to have his or her teeth straightened or is informed that orthodontic therapy is recommended, he or she should be told why it is in his or her best interest to undergo such treatment. The most common reasons for seeking treatment are:
• to improve cosmetics (crooked teeth, overbite, etc);
• to facilitate other necessary dental work (to properly position teeth for capping, bridges, or implants);
• to correct a jaw discrepancy or skeletal disharmony (one’s bite is off); or
• to help patients maintain their periodontal status (the health of the supporting gums and bone).
The next step is to gather necessary information by obtaining diagnostic records. The following diagnostic materials are most often obtained:
• x-rays of the teeth to determine how sound they are and whether the bony support for them is adequate;
• a film of the skull to see the relationship of the teeth to the jaws and the jaws to one another;
• photographs of the face to assess one’s profile and the effect that any proposed tooth or jaw movement may have on it;
• a clinical exam to check for cavities and gum disease; and
• a review of your medical history, as there are many underlying physical problems that can impact on the success of orthodontic therapy.
A consultation between the orthodontist and the patient will then follow. At the consultation visit, your orthodontist should explain to you what the actual problem is in a language you can understand. You should be told why correction is advised and how it is to be achieved. You should also be informed of all reasonable alternative methods of resolving your particular problem. As no form of medical treatment is without the potential for some risks, limitations, or compromises, you should be made aware of those that pertain to your specific situation. Next, you should be told what result you can expect to achieve; and finally, what will occur if no treatment is undertaken.
At this time, the fee for the services to be rendered should be discussed in full, and suitable financial arrangements should be made between you and your orthodontist. Make sure that you have had the chance to ask and have answered all questions regarding your treatment, as well as how long it will take and the financial responsibilities you are assuming. It is now time to begin treatment.
The appliances or braces will be specifically tailored to your particular problem. You may require permanent and/or removable appliances. Once they are attached to your teeth, make sure that you have been given careful instructions on how to care for them. Check to be sure that your orthodontist will either be available or will provide for coverage if an emergency (breakage) arises. You also need to be informed of your responsibilities in order to achieve the best results possible. Some of these are the following: maintaining good oral hygiene, wearing rubber bands or a headgear as instructed, and keeping your regularly scheduled appointments. You must continue to see your general dentist at least twice per year unless your orthodontist recommends otherwise.
At the completion of active treatment, you will undergo a period of retention care. This phase of treatment is necessary to monitor and help maintain the results achieved. An appropriate retainer will be fabricated to maximize the stability of the finished result. Remember, nothing lasts forever, and some movement of your teeth over the years is normal and should be expected.
Orthodontic therapy carries many benefits. You can only evaluate these if you have been given sufficient information on which to base your decision to undergo care. You have a right to know; to be educated is to be able to choose wisely.
After the patient’s records appointment, give him or her two copies of the next form. Ask him or her to read it at his or her leisure and bring a signed copy with him or her to the consultation appointment.
Information Concerning Your Treatment
Every medical or dental procedure carries some degree of risk, and orthodontics is no exception. Fortunately, most of the risks involved with undergoing orthodontic therapy don’t even come close to canceling out the tremendous benefits that patients achieve by undergoing treatment. Please indicate to us that you are aware of the following possibilities associated with correcting your bite, straightening your teeth, and providing you with a beautiful smile, by initialing the paragraphs listed below.
CAVITIES AND DECALCIFICATIONS
Braces don’t cause cavities—poor oral hygiene does. Proper brushing will help reduce the likelihood of developing cavities or decalcifications (white scarring of the enamel around the outside edges of the braces). Finally, loose appliances can also lead to these problems, so report any breakages to your orthodontist. You must continue to see your regular dentist for checkups at least twice per year. Do not expect your visits with us to replace your regular dental examinations.
PERIODONTAL (GUM) DISEASE
Some patients will experience various degrees of breakdown or loss of the bone and/or gums supporting their teeth. While some patients are more predisposed to this condition than others, most of the time it is due to poor oral hygiene. If you experience this problem, you may have to see your dentist or a periodontist for treatment three or four times per year. On rare occasions, your treatment may have to be interrupted or even discontinued if this condition cannot be effectively treated or controlled.
On very rare occasions, the nerve of a tooth may die during orthodontic therapy. This is almost always caused by trauma (even from years ago) to the affected tooth or a deep filling. If this occurs, a root-canal procedure to remove the dead nerve and save the tooth may be required.
It is very common for the roots of some of the teeth to shrink in size during orthodontic treatment. This root shrinkage even occurs in people who never wear braces. As long as your teeth and supporting structures are healthy, a small degree of root shrinkage does not matter to your overall dental health. However, as you grow older, if you develop periodontal disease as described above, the combination of the two might affect the longevity of your teeth. If this condition becomes severe (a rare occurrence), your treatment may have to be discontinued before it is completed.
Your temporomandibular joint (TMJ) may become affected during orthodontic treatment. Clicking, locking, limitation of movement, and pain in the joint or facial muscles have all been reported to occur. This problem also occurs in people who have never undergone orthodontics—and as a matter of fact, orthodontic therapy is often recommended to help correct a TMJ problem. Usually this condition is temporary, disappearing after treatment is completed. If it persists, tell us. You may need to see other physicians to address this problem.
Throughout life, all tissues in the body change with the aging process. Your teeth and supporting structures are no different. The retention phase of therapy can minimize the movement of your teeth after treatment is completed. Teeth can shift position for a number of reasons, such as excessive and/or unanticipated growth or uncorrected oral habits. Wearing your retainers as instructed can help maintain the results achieved.
All orthodontic appliances have the potential to cause injuries. If they are properly used and worn, this is usually not a problem. Removable appliances may cause reactions to those allergic to acrylics. The braces themselves may affect those with nickel allergies, and ceramic braces have been associated with injuries to a tooth’s enamel surface. The latex gloves we wear for your protection may affect those sensitive to latex. If you experience oral trauma, the braces themselves have been known to make some injuries worse—while at other times, they have actually prevented more serious injuries from occurring. Finally, headgears (night braces) and elastics (rubber bands) have been associated with eye injuries. There have also been reports of patients swallowing parts of their braces. Your braces are not toys; proper care and maintenance will minimize the possibility of any untoward occurrences.
Orthodontics, like every branch of medicine, carries no guarantees. Sometimes, despite our best efforts, the results achieved are less than anticipated; although they almost always result in significant improvement.
The most common reasons for achieving a less than ideal result are the following: the decision to treat a limited problem as opposed to the entire problem; underlying skeletal, anatomical, or periodontal limitations; treatment rendered by other doctors; delays in beginning treatment as recommended; and, most often, poor patient cooperation as far as not following treatment instructions and recommendations, not keeping appointments as scheduled, and chronically breaking, loosening, or losing the appliances.
NECESSARY SECONDARY TREATMENT
Other treatment is often required in conjunction with your orthodontic therapy, such as routine dental checkups, caps, extractions, gum treatments, and implants. You must ensure that these procedures are performed in a timely fashion. Also, any fee associated with these treatments is separate from the orthodontic fee charged.
As your teeth move, they may become slightly loose, and this may be uncomfortable. Patients usually get used to this within a short period of time, and once the braces are removed the teeth tighten up again. If you are having any pain, call us. Let us help. Also, your teeth may hurt for a day or two after an adjustment. This is normal, and simple over-the-counter painkillers will be helpful.
STOPPING THERAPY BEFORE COMPLETION
The orthodontist/patient relationship needs to be respected by both parties. We will use our best efforts and judgment in exercising our skill, knowledge, and experience to provide you with a quality orthodontic result and experience. We will respect your confidentiality, your time, and your values. In return, we ask for your cooperation with regard to keeping scheduled appointments, following all instructions, and promptly paying for services rendered. We reserve the right to discontinue your treatment, even though treatment may not be completed, if problems of this nature persist without adequate resolution on your part.
Like all health care providers, my orthodontist may have to consult with other health care professionals concerning my treatment. Permission is hereby granted to exchange medical and dental information about me/my child only as it relates to providing and paying for orthodontic treatment. In addition, I give permission for photos, x-rays, models, and clinically relevant data of me/my child to be used in scientific publications and/or presentations, and for no other purpose.
My orthodontic treatment has been thoroughlydiscussed with me. I have had the opportunity to ask questions about myproposed treatment, and I understand the potential benefits and risks asnoted above.
I also understand that during treatment, circumstances may arise requiring either a discontinuation of or a change from the original treatment plan. If either of these occurs, it may result in adjustments to the cost of treatment. Lastly, I understand that the fee presented to me is only for orthodontic treatment, and if other dental treatment is necessary, there will be additional fees charged for those services.
The information noted above is solely so you, an informed consumer, can better appreciate that all medical treatment, including orthodontics, carries some small downside risks. Fortunately, these risks are minimal and can be easily dealt with, should they occur. The tremendous benefits associated with orthodontic therapy far outweigh any potential negative occurrences associated with treatment. We encourage you to ask questions of us before, during, and after treatment so that you become one of our most important assets: a happy and informed orthodontic consumer.
Signature of Patient or Date
Parent if Patient is a minor
Obtaining a patient’s informed consent, when done appropriately, can be a very rewarding practice-, patient-, and risk-management procedure. It fosters a close orthodontist/patient relationship by putting all parties on the same track regarding the diagnosis, treatment plan, and prognosis. Your patients will understand and appreciate more of the complexities that are involved with their orthodontic treatment, and thereby will have a greater respect for the fees charged. It gives the orthodontist an aura of openness, honesty, and caring. All in all, if used as a sword and not a shield, it will serve to benefit the patient, the orthodontist, and the profession through open communication.
Laurance Jerrold, DDS, JD, is the dean and program director at Jacksonville University School of Orthodontics. He can be reached at (904) 256-7852 or at [email protected].