5 Rules of GDP Orthodontics

1 Careful Assessment of the patient:

Sometimes when one attends a course on a topic which offers an interesting diversion from the routines of day to day practice one becomes excessively focussed on that particular aspect and consequently we see problems and solutions which we have not previously noticed. This is particularly true in relation to cosmetic dentistry. I well remember taking a course at the Eastman on submucosal implants which made me focus on trying to provide them on any patient who had an ill- fitting upper denture instead of honing my technique on getting accurate impressions with muscle trimming and occlusal balance.

What I am really saying is that it is natural to look at patients with a somewhat jaundiced eye just after learning something new. The next masterclass will alter our focus yet again.

So, with this clearly in mind, it is essential that, when talking to patients about potential orthodontic treatment, you undertake a thorough assessment and make accurate, contemporaneous notes of what was said including the possibility of iatrogenic tooth damage or changes to the patient’s profile. It seems to be important to be absolutely certain that all pros and cons are clearly understood by the patient – though how you can be sure of this is a moot point.

2 Careful explanation of the process:

Given the above and the ruling changes which emerged from the Montgomery Case about what constitutes patient consent ( See Link ) https://www.medicalprotection.org/uk/for-members/news/news/2015/03/20/new-judgment-on-patient-consent

all persons undertaking treatment are affected and that includes us dentists; it is essential to give as full an explanation of the treatment process as the patient will allow you to give. Some patients, especially those who have been recommended for a particular procedure, often do not want an in-depth discussion about the process. But, if this is the situation ensure that this is written in the case notes.

It will help if you can supply your patients with photographs and leaflets showing the process so that they have something to take away and digest and can ask questions about should that be required.

Usually Oralign will supply a projected outcome image which can be shown to the patient for their approval. However, it is vital that you explain the changes because patients are not usually familiar with observing their own dentition.

3 Choosing the right cases:

As in most things in life careful selection is most useful in avoiding complaints or patient dissatisfaction. Over the last couple of years Oralign has come across a couple of cases where patient expectation has crept up as the results begin to emerge. I suppose one could liken it to watching a pupa of a cabbage white butterfly break open and expecting a red admiral to emerge. Realism gets suspended and disappointment takes over even when the result is exactly as promised. This can be a particular problem when patients say they just want treatment to one jaw and the disadvantages of this are clearly pointed out e.g. increased overjet because the upper teeth have been moved forward a little to make space for an imbricated incisor. Had both jaws been treated the overjet could have been maintained at its original level as the teeth would have moved in line with each other. The moral, we have learned, is if the treatment really requires that both jaws are treated to get the best results both aesthetically and functionally, then insist that this is the treatment plan which has to be undertaken or do not take on the treatment – it will lead to misery for you and for the patient. You will find yourself in the dilemma of having pointed out the disadvantages of single arch treatment but the patient will claim a failure to comprehend and that will cost you time and money. The patient will convince themselves that you were not competent and misled them which leads them to denigrate the service you gave and tell the story of their ‘failed’ treatment to the amusement of all who hear it. But, the net effect will be that the patient’s acquaintances will not roll up for treatment and will continue to spread the story. Oralign wants you to achieve success and gain patients who will become ambassadors for your treatment.

4 Understanding patients’ desires:

Before embarking on explaining to your patient what you can, with Oralign’s help, achieve for them be sure that you clearly understand what they would like to achieve from treatment. I remember many years ago advising some treatment to a patient who wanted some new dentures. In due time I produced some dentures which, to us, seemed to be the bees knees. They fitted very well, were stable and looked like natural teeth. She could speak well with them indicating that I had got the teeth in the right position and that the lengths of the anteriors was right – we had her trying all the explosive consonants and tongue twisters – but the patient hated them. She reverted to her old NHS dentures because all the very detailed gingival contouring and the simulated rugae- a copy of her own natural rugae – felt strange. We finished up removing all this lovely contouring and converting them to an upgraded version of her old NHS dentures because ‘they felt right’. I was heartbroken and so was the technician who had laboured long and hard to no avail.

What I got wrong was that I did not explore fully enough what she liked about her old dentures and I solved problems she did not have. So, make absolutely certain that when you are embarking on orthodontic treatment that you fully understand what the patient would like you to achieve. Then when you write up the notes on the Oralign system you give a full explanation of what is expected to the supervising and planning registered orthodontic specialist who will diagnose and monitor your patient’s treatment in order to be sure we achieve the patient’s desires.

If the patient’s desired result cannot be achieved Oralign will tell you so before treatment begins.

A Class ii malocclusion – moving the uppers forward will increase the overjet – moving the lowers at the same time will alleviate a feeling that the bite has become dysfunctional.

 5 Establishing the Do’s and Don’t’s:

I have always believed that patients have obligations when they undertake treatment with us in the same way that we, as professionals, also have obligations to provide efficacious treatment. So, over the years I have always found it wise to point out to my patients what is expected of them and what is expected of me.

With removable orthodontic appliances my daughter proved many years ago to the chagrin of her treating orthodontist, Hans Eirew, that if the appliance is not actually in the mouth it will not move the teeth. This patient compliance aspect should be clearly outlined in detail before the start of the treatment. Aligners which are left in the drawer/handbag will benefit no one and your patient’s teeth will not miraculously re-arrange themselves into the desired positions.  Wearing the appliance for less than the optimum time per day will extend treatment time considerably. Aligners which have not been worn for some time will, usually, not fit back in because the teeth will have relapsed so the patient may have to revert to a previous aligner to re-start the treatment.

There is a definite benefit to using fixed appliances; which is that they are in place and cannot be ‘forgotten’. However, we, at Oralign, have experienced a patient who seemed to have the knack of detaching the brackets and wires whenever she had a ‘special’ social occasion to attend and then blamed the dentist for not fixing them properly. Any semblance of fairness in these things Oralign has, by experience, learned does not exist. There are some patients who will use all the tricks to get what they want and lay the blame elsewhere. This was grossly unfair to this practitioner because it cost him added time and added expense to replace the brackets and wires. Life can be very hard and very unfair.

One final tip is always under- promise and over- deliver; it leads to greater patient satisfaction.

The above is not an exhaustive list but it is a good sound basis upon which to build.

Lester Ellman Dec 2016

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