1. Take excellent quality and comprehensive records before, during, and after treatment

Orthodontic records include comprehensive medical, dental, and social histories; extraoral frontal and lateral photographs; an appropriate means of memorializing the intra-arch and interarch occlusal relationship and the status of the hard and soft tissue structures by photographs, scans, or models of the dentition; and appropriate radiographs to visualize the dentoalveolar structures and the dentofacial and skeletal relationships as specific cases dictate. It is especially important to take panoramic or intraoral radiographs about 9 months after initiating treatment to monitor for root resorption and to continue to do so at least once annually. Your staff needs to appreciate the importance of quality records acquisition. Poor-quality records have often been the basis of litigation. Intraoral photography is an excellent means of documenting poor clinical response or cooperation. Cone-beam computed tomography is beneficial in certain patients for 3-dimensional evaluations of impacted teeth, temporomandibular joints, pharyngeal airway, and other structures.

Because adults have different physiologic factors than do adolescents, such as periodontal condition and healing capacity, their treatment should take these and other clinical factors into greater consideration. Because of the greater propensity for interdisciplinary treatment with adults, additional records are often required, including periodontal charting, periapical radiographs, temporomandibular joint examinations, and detailed medical and dental histories. Since periodontal disease is episodic, a history of past periodontal treatment is vital. Patients with previous periodontal disease may be at greater risk of developing periodontal breakdown during orthodontic treatment.

All diagnostic records require evaluation—at least qualitative if not quantitative assessment. Whether examining an intraoral photograph or a cone-beam computed tomography scan, it is not difficult or unusual to detect clinical abnormalities or pathology. Be sure to document that the patient was informed about the condition as well as any referrals made.

2. Meticulously clear every patient for orthodontic treatment

Orthodontists frequently request clearance from the general dentist before starting treatment. Clearance by the general dentist, pediatric dentist, or periodontist is important not only for the patient’s benefit but also for risk management purposes. Regardless of any clearance obtained, the orthodontist is still responsible for the treatment rendered, since he or she is the treating practitioner. Relying without question on another doctor’s clearance is inappropriate unless you concur with his or her findings. The orthodontist should continue to monitor the oral cavity during treatment and strongly encourage all patients to visit their dentists for regular “cleaning and cavity checks” before, during, and after treatment.

2. Meticulously clear every patient for orthodontic treatment

Orthodontists frequently request clearance from the general dentist before starting treatment. Clearance by the general dentist, pediatric dentist, or periodontist is important not only for the patient’s benefit but also for risk management purposes. Regardless of any clearance obtained, the orthodontist is still responsible for the treatment rendered, since he or she is the treating practitioner. Relying without question on another doctor’s clearance is inappropriate unless you concur with his or her findings. The orthodontist should continue to monitor the oral cavity during treatment and strongly encourage all patients to visit their dentists for regular “cleaning and cavity checks” before, during, and after treatment.

3. Obtain the appropriate informed consent from each patient

Obtaining the patient’s informed consent before any treatment is essential to ensure his or her understanding of the proposed treatment, agreement to proceed with the treatment despite its limitations and inherent risks, and understanding of all viable alternative options, including no treatment, and the associated risks and benefits associated with each. All risks and limitations discussed should be documented. Atypical or unusual cases often require additional express consent. For example, cases involving impacted teeth require the patient’s understanding of the risks of ankyloses, damage to adjacent teeth, devitalization, prolonged treatment, and compromised final positioning of the teeth or surrounding hard and soft tissue support. Specific consents should be obtained when dealing with impacted teeth, periodontal diseases, mini-implants, bisphosphonates, and laser use. Documentation that the patient’s consent was obtained takes many forms, ranging from no documentation to videotaping the consult, a practice that requires the patient’s awareness of being taped in some states. Consider acquiring additional progress records to support any changes in the initial treatment plan.

4. Do not promise or guarantee anything, and outline the limitations of treatment

Making promises can lead to claims of false advertising. Orthodontic treatment benefits are usually dramatic; however, there are nearly always limitations. Normalization as opposed to perfection is often a better stated approach, and total correction should never be guaranteed. Since nothing lasts forever, the treatment results may not be stable in the long run, even if a retainer is worn. These limitations should be discussed, perhaps at greater length than the treatment’s benefits. A posttreatment consultation outlining not only what was achieved but also what was not is a viable risk management tool and should be documented and preserved.

5. Do not let the patient dictate the treatment plan

Patients who dictate treatment plans are common. Not only are orthodontists liable for any treatment they render, but their performance is optimized when they pursue treatments and techniques that they have already mastered. Although patient autonomy is highly valued in contemporary bioethics, the patient is usually best served when the doctor and the patient collaborate in formulating the treatment plan. Patients have autonomy, but so do doctors, and they are not required to render treatment that they are not comfortable providing or believe is not in the patient’s best interest.

6. Do not let the laboratory dictate the treatment plan

The most frequent situation in which an orthodontic laboratory plans treatment occurs with clear aligner therapy. No matter how large or influential the laboratory is, it is the doctor’s responsibility to acquire full records, make a diagnosis, formulate a treatment plan, and undertake treatment. The doctor should determine from the beginning whether the patient qualifies for aligner therapy, since he or she will shoulder most of the potential for liability. The bottom line is to allow the patient to proceed with aligner therapy after fully understanding its benefits and limitations.