Calling it quits

I received this e-mail the other day, and it forms the basis for this month’s column.

Larry: What is our actual responsibility to follow patients in retention? I follow up my patients for a minimum of 5 years, but many colleagues of mine only track their patients for 6 to 12 months. Is there a standard of care for when to dismiss a patient who is in retention? Thanks, M.A.

Our reader asks questions that have plagued a lot of us for some time. How long should a patient be kept in retention? What should be the protocol for retention? Are there recognized guidelines or standards regarding this issue? What happens at the end of this period, and what should a patient be told? All are important issues, but, unfortunately, there is no bright-line legal standard that addresses them. To find our answer, we must use the “reasonable person” standard, and, in this case, our reasonable person happens to be an average doctor in good standing in the community where he or she practices. It always gets back to the basic standard-of-care question and response.

To begin with, the standard of care is, for the most part, determined by what the reasonable practitioner should do or refrain from doing in a given situation as measured by what an average practitioner with similar training and experience would do under the same or similar circumstances. How should this be determined? It is essentially a 3-prong test. The first prong is that the doctor in question must possess an average degree of “SKE.” SKE is the mnemonic for skill, knowledge, and experience or expertise. The required level of SKE is that possessed by an average orthodontist who has completed an accredited advanced education training program; it is usually through that endeavor that orthodontists possess similarly minimal acceptable levels of SKE.

The second prong of the test is that the doctor must exercise his or her SKE reasonably. Again, this is determined against the average practices of similarly trained doctors, only this time we add the phrase “acting under the same or similar circumstances in the same or a similar community.” We do this to recognize that there can be certain restrictions or limitations relating to the treatment of our patients. These limitations might be anatomic, or relate to a patient’s acceptance of only partial or limited treatment, to access-to-care issues since patients might not return for follow-up visits or a second phase of treatment, or to lack of patient cooperation. Likewise, consideration should be given to a patient’s poor physiologic response and so on. This second part relates to the fact that, depending on where we practice, certain parts of the country do not have the same wealth or depth of interdisciplinary specialists and ready access to certain diagnostic tools, and there might be other geographic or demographic limitations.

Now that we have established the degree of SKE required and the level at which it should be exercised, the third prong of the test is that the doctor must use his or her best judgment for each patient. Essentially, one should do the things that everyone else is doing in a similar manner as everyone else is doing. One should also stay away from approaches that are not being practiced by a “respectable minority” of one’s peers. Acquiring appropriate diagnostic material, rationally interpreting the resulting data, designing a treatment plan to address the patient’s goals and objectives, and effectively and efficiently implementing appropriately designed mechanotherapeutics for those treatment goals, including making any necessary midcourse corrections, demonstrate appropriate judgment.

All of the above will be determined by a jury, which has been told whether the defendant deviated from the standard of care according to expert witness testimony. The expert for each side will perform the following functions. First, the experts will translate orthodontic Dentalese into English. They will then give opinions about the standard of care in the community under discussion. Next will be an opinion about whether the standard of care (the duty owed) was breached and, if so, how. The expert will then discuss the plaintiff’s injuries in terms of severity and effect. Finally, the expert will opine whether the injuries were directly or proximately caused by the breach of the standard of care.

Okay, so what does all of this have to do with our reader’s questions? The first question asks, how long should a patient be kept in retention? The answer is what does the average orthodontist in your area do when treating similar patients? What should be the protocol for retention? The answer is to do what everyone else does and use your best judgment in doing so. Are there recognized guidelines or standards for this issue? I don’t know of any. There are rules of thumb that we have all been taught, but guidelines—fat chance. What happens at the end of this period and what should a patient be told? Do and say what reasonable orthodontists would do under the same or similar circumstances. The answers stink, don’t they? Welcome to the vast expanse of the great unknown known as clinical orthodontics.

Commentary

You didn’t really believe that I would leave you good readers hanging, did you? Okay, let’s look at this rationally. How long should a patient be kept in retention? Since there are no established guidelines on this issue, we might want to think about developing some for ourselves. Talk with the members of your local study clubs and come up with a rational rationale for retention. Discuss these issues at your local and component meetings, since they truly reflect the community in which you practice. Remember that you need to be doing only what the average doctor in your community is doing under the same or similar circumstances.

Wouldn’t you retain a patient with severe crowding longer than one with a simple anterior crossbite? Wouldn’t you maintain a growing patient with a maxillomandibular discrepancy longer than one with a simple Class I malocclusion and blocked-out canines. The point is that the retention phase of therapy is not one size fits all. The retention phase should be tailored to each patient in much the same way that your differential diagnosis is constructed and the choice of mechanics is individualized for the clinical situation. Retention therapy does not mean just placing retainers. Retention therapy runs the gamut from observation to fixed retainers and encompasses such adjuncts as equilibration, soft-tissue surgery, and various forms of enamelplasty (reproximation), to name a few. The goal of retention therapy should be to titrate the patient down to the minimal time necessary in the retention modality of choice that is required to maintain the desired result. This takes time, effort, and observation. Use the following thoughts as a template in your discussions with colleagues. Putting something down on paper will often help you to develop a clinical rationale for doing what you are doing and might help to show that you used your best judgment in treating your patients.

Diagnostic considerations

Retention begins with the original diagnosis and treatment plan. However, because the outcome can vary from what was originally expected, the retention protocol for every patient must be reviewed and modified if necessary after active treatment. The following variables should be considered in determining a patient’s retention protocol: (1) the original malocclusion with particular emphasis on the clinical manifestations with a high relapse potential; (2) the original treatment goals; (3) the clinical results obtained; (4) the expected cooperation with the retention protocol to be used; and (5) the potential for changes secondary to dentofacial growth and development. Protocols for retention should also take into account any ancillary procedures to be performed, the types of retainers to be used, and the time frame for their use.

Some types of corrected malocclusions offer “self-retention”; however, most corrected orthodontic problems require some retention therapy. Retention therapy runs the gamut from observation, soft-tissue surgical procedures, reproximation, and removable appliances to fixed permanent retention. Every attempt should be made to identify, to whatever extent possible, the clinical manifestations that will require retention therapy and what form this intervention should take. Ideally, all of this should be discussed at the consultation visit, because every patient has a right to know, before treatment, (1) what the treatment will entail, (2) what the long-term prognosis is for stability of the finished result, (3) whether other procedures or devices will be necessary to maintain the results, (4) what the patient’s contribution must be in terms of cooperation with the retention protocol, (5) what the projected time frame is for this stage of therapy, and (6) what additional costs are associated with the retention phase of therapy if they are not included in the original fee.

Temporal considerations

Retention therapy is an important phase of orthodontic treatment. Active treatment cannot exist in a vacuum. Since every patient’s treatment is predicated on the diagnosis and treatment plan for the particular problem, the only way to objectively measure the efficacy of any treatment approach is by monitoring the results achieved during the retention phase of therapy. It is one thing to say that a given mechano-therapeutic approach to a certain orthodontic malocclusion was effective in resolving, to whatever degree, that problem, but that would take treatment out of context. A truly effective treatment affords the patient the trilogy of function, stability, and esthetics. Many methods of active treatment will produce an esthetic and functional result. Unless we can evaluate a patient not only after treatment but also after retention, we have no way to ascertain the stability of the results. By evaluating patients in retention as well as postretention, the practitioner becomes a lifelong student for the benefit of his or her patients.

The lessons learned include, but are not limited to, (1) how various skeletal, dentoalveolar, and dental relationships respond, first, to a certain treatment modality and, second, to the retention methodology; (2) the role of dentofacial growth and development in the short-term and the long-term stability of the treatment; (3) the role of functional and parafuntional influences concerning the dentofacial complex, particularly when coupled with environmental influences, on the results; and (4) most importantly, the role of natural physiologic changes over time in the provision and stability of orthodontic services.

Record-keeping considerations

After active treatment, the patient’s retention needs must be thoroughly reviewed. Posttreatment records should be obtained when the fixed appliances are removed, whether or not retainers are placed. Postretention records should be obtained after the retention phase of treatment. At this point, the patient should be classified as dismissed. Don’t minimize this step, because the doctor-patient relationship is then over, and the statute of limitations can begin to run. Upon its expiration, patients can no longer to bring a malpractice action against you. Patients who voluntarily discontinue their treatment before completion and against medical advice, or those who have been dismissed because of poor cooperation in following instructions, hygiene, appointments, appliance breakage, financial delinquency, best interest of the patient, and so on, regardless of the patient’s phase of treatment, should also be classified as dismissed for the same reason. Every attempt should be made to obtain photographic and panoramic records at a minimum for these patients.

Clinical orthodontics involves, in part, the ability to study the different malocclusions and the effect of various forms of mechanotherapy on the treatment of these orthodontic problems as well as how the final results are best maintained and respond to various factors over time. Evaluating both the short-term and long-term efficiency and efficacy of differing treatments and retentive modalities can only be accomplished with comprehensive posttreatment and postretention records.

The final question from our reader was “What happens at the end of the retention period and what should a patient be told”? At some point, every practitioner must purge patients in retention to have the time to treat new ones. Patients should be told exactly that: nothing more can or needs to be done, and they have received the benefits of orthodontic therapy, which took an abnormal situation and made it normal (normal is a range, not a point). Patients should be told that some normal changes will occur with aging, as in every other part of the body. They should be told that they are welcome to return if they encounter any problems, but an additional fee will be charged for those ministrations. Finally, they should be told that you were glad to be of service to them and that you welcome expressions of their gratitude in the form of new referrals. Don’t be shy; you have earned it. You have given a person one of life’s greatest gifts; you have changed the patient’s face and self image. For the most part, that gift is something he or she will carry for many years to come.

We all joke about the few patients who didn’t quite turn out as we had planned and how we now are hoping for geographical success (the patient moves). Well, we all must deal with the realities of less-than-ideal results, which in no way mean that malpractice was committed. When this situation occurs, the advice is no different. Tell the patient what was achieved and what was not achieved. Say that these results were monitored during the retention phase of therapy and that they are relatively stable (they should be if appropriate retainers were used). Mention again the normal changes that are expected over time. Give the same mantra about your availability for return visits in the future. Finally, look them straight in the eye and ask for the same expression of gratitude. You did the best that you could under the circumstances. You made a significant improvement, even if all treatment goals were not totally met. We practice a healing art. Not every patient will be a rip-roaring success. At least, our patients don’t die on us—not usually, anyway.

In summary, embrace your knowledge and retain it.

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Apr 13, 2017 | Posted by in Orthodontics | Comments Off on Calling it quits
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