Negligent orthodontic care – what you need to know about dental negligence

Orthodontics is a specialist branch of dentistry. Generally orthodontists will perform this treatment, however more and more general dental practitioners are now offering orthodontic treatment in the form of fixed braces and brands like Invisalign.

So what should you expect if you are thinking about treatment? In this guide, we explain what you should expect from the process.

• Planning for your orthodontics
• Treatment
• Retention

We should stress we are legal rather than dental professionals, however we have built up a significant amount of evidence from expert witnesses, who have assisted us in bringing a large number of successful claims against general dental practitioners and orthodontists over many years.

Planning for orthodontics

Whether or not you consult a general dentist or a specialist orthodontist you should expect a thorough planning phase.

Your aims

All orthodontics is optional, so it is essential that your treatment aims are carefully recorded and taking into account. The treatment should be directed towards what you have expressed is your goal from the treatment, whether that’s to reduce gaps or just straighten your teeth. This would then be continuously referred to throughout the treatment.

You may attend a dentist and enquire about a specific mode of treatment, invisible braces for example. Whilst this is absolutely reasonable it would be important that the practitioner also suggests other treatment options. Just because a patient doesn’t want visible braces it doesn’t mean that their preferred treatment option will provide the best outcome for their aims. And of course, not having treatment at all should always be on the table.

Primary care issues

At a planning examination the practitioner should carry out an analysis of the soft tissue in and around the mouth both internally and externally. The condition of all of your teeth should be very carefully recorded.

If there is decay or infection then these should be dealt with (either by the orthodontist or your general dental practitioner) before orthodontic treatment begins. It is a requirement that all primary care issues are resolved so that the certain prognosis of each tooth can be established.

Skeletal pattern and occlusion

An analysis of the skeletal patter on the face should then follow, regardless of who is providing treatment. Failure to do this, even if only minor movements of the teeth are needed, could lead to further significant issues after treatment.

The analysis would ideally involve taking photographs of the face from several different angles. This would be to determine the role of the lips and tongue and any special features of the face such as asymmetry and fullness or flatness of the face. Again, this would feed into the treatment plan and your own aims of treatment.

The examination of the teeth should also assess occlusion; i.e. how your teeth close together. Each tooth should have a relationship with the corresponding tooth above and below and this allows the practitioner to diagnose a specific occlusion type. Study models should be taken of the teeth with putty in order to review this, and these should be both upper and lower even if only single arch treatment is being planned.

The importance of x-rays

There should then be special investigations, wherein x-rays are important.

There are several different type of dental x-ray.

• Bitewing x-rays provide images of the back teeth for the purposes of diagnosing caries (decay).
• Periapical x-rays capture images of the roots of specific teeth to diagnose infections. OPG radiographs show the whole mouth and can assist in diagnosing bone levels.
• A lateral cephalometric x-ray is probably the most important in terms of orthodontic treatment planning. This is used to verify the facial skeletal pattern and special position of the dentition including the upper and lower incisors angulation. It also allows for monitoring of the change of and occasional unwanted, tooth movements.

Many dental negligence cases are defended on the basis that a lateral cephalometric x-ray is not mandatory or necessary in all cases. Evidence from our expert witnesses states that this is not the case though, and that the failure to take one would fall below the standards of a reasonably competent general dental practitioner and orthodontic specialist, thereby satisfying the legal grounds for negligence.

Extraction of teeth

After all this has been done, your practitioner should then present you with the diagnosis and multiple treatment options including the option of no treatment.

Very often in orthodontics, extraction of teeth is recommended. Especially in an overcrowded arch. You should obviously consider this very carefully, as it is important to extract the right teeth. Those with a poor prognosis for example should be considered ahead of healthy unrestored teeth.

All this is not to say that healthy teeth cannot be extracted, but it highlights the need for thorough planning and diagnosis of all teeth so that you can make an informed decision on the treatment. Without this, there would be an argument that you could not provide your full, informed, consent to treatment.

Retention

Finally, in the planning stage we would expect that you are fully informed of what retention will be necessary once the braces are removed. Some form of retention is always necessary.

There are two types of retention, fixed and removable. Both have an impact on your choice of treatment in order to retain the end result and stop the teeth relapsing to their original position.

It is our expert opinion that the lifetime costs of retention should be included in the treatment quote. We have seen treatment plans that detail two courses of retention but the long-term retention over a lifetime would add up to thousands in addition.

The Treatment Phase

Once you have chosen your treatment the braces will be placed or bonded to your teeth.

It is important that the practitioner monitors each and every movement of your teeth in detail. Noting how much a tooth has moved specifically is vital to the ongoing success of treatment and should a different practitioner need to treat you, they will have all the information necessary to make adjustments. Too often, we see “braces adjusted” as the only record of what took place, which is wholly unsatisfactory.

You should be invited to be seen regularly and it is important to stress that your own compliance with these appointments is vital to the success of the treatment. Failing to attend even for a review might impact negatively on the treatment. You must be prepared to play your part as, if you do not attend, not all failures in treatment can be directed at the practitioner.

The Retention Phase

At the end of the treatment, you will be provided with either a fixed retainer bonded to the back of your teeth, or a removable retainer to wear during the day or night.

Retainers are essential, especially in adults, but the period of retention will vary. In our experience, it should probably continue for 12-24 months if removable retention is needed.

As you can see, there is a lot that goes into the planning and execution of good orthodontics. If you have experienced a dental injury as a result of orthodontics, it is certainly worth considering whether all the steps above were actioned as a part of your treatment.

If you want to speak to our specialist dental solicitors about it though, please do contact us today – we’d be happy to help you understand your options. In the meantime, please do read our guide to the process of making a dental negligence claim here.