A reader sent in the following question.
Larry: In talking at recent meetings to fellow orthodontists, it seems that a rising number of people are taking only intraoral and extraoral photographs along with a panoramic radiograph as their initial and final records and are not taking study models. In addition, they are only taking a cephalometric radiograph if they feel the case warrants one. I am presuming they believe they can make a proper diagnosis using just the photos and a pan. As a young orthodontist, the potential for litigation and making sure I have all the necessary records for each patient has strongly been ingrained in me. What is the legal standard of care relating to what orthodontic records need to be acquired? Thanks, D. K.
This question arises all the time, so let’s see if we can put it to rest. First, we need to recognize that there is no universal standard of care regarding this issue. In any case that gets litigated and where this question becomes an issue, the expert witnesses will opine about the standard of care for that particular case. However, let’s try to apply a little of one of our lesser-used senses: common sense. First, we need to look at the definition of the practice of dentistry. Every state has a definition in its dental practice act; I’ll use New York’s as an example. State Education Law, Art. 133, Sec. 6601 states the following.
The practice of the profession of dentistry is defined as diagnosing, treating, operating, or prescribing for any disease, pain, injury, deformity, or physical condition of the oral and maxillofacial area related to restoring and maintaining dental health. The practice of dentistry includes the prescribing and fabrication of dental prostheses and appliances. The practice of dentistry may include performing physical evaluations in conjunction with the provision of dental treatment.
Using the language in the definition, let’s ask the following question. What information does one need to adequately and appropriately diagnose, prescribe a plan of treatment, and then render whatever treatment is required to address a dental deformity or physical condition for the patient that results in restoring or maintaining to some degree his or her dental health? That is the question that will yield the answer to our writer’s question.
Would anyone advocate the need for a lateral cephalometric film to diagnose and treat a nongrowing adult who has good facial balance, an orthognathic profile, and a good Class I occlusion, and comes for esthetic correction of mild maxillary and mandibular crowding (<3 mm)? Many if not most would say that it’s just not necessary. Would anyone advocate the need for study models to diagnose and treat a 7-year-old with good facial balance and harmony, and a panoramic film that shows an absolutely normal early mixed dentition with a normal occlusal scheme except for a maxillary central incisor with a 1-mm crossbite? Again, for this patient, many if not most of us would posit that it’s just not necessary. In neither instance would you need the diagnostic record in question to arrive at a proper diagnosis or treatment plan for that patient. Well, if we don’t need certain records in those cases, when do we need any given diagnostic record? Let’s delve deeper into the purpose of diagnostic records.
The 5 main orthodontic diagnostic records are (1) an appropriate medical and dental history, including the patient’s chief complaint or reason for seeking your opinion or treatment; (2) an appropriate means of assessing and memorializing the patient’s orofacial and extraoral presentations (frontal and lateral); (3) an appropriate means for assessing and memorializing the patient’s hard and soft intraoral tissues and their interarch and intra-arch relationships; (4) appropriate radiographic images to document the status and the health of the patient’s skeletal and dentoalveolar structures, considering the degree of insult of the orthodontic intervention on them by virtue of the treatment plan selected; and (5) a memorialization of your clinical examination and findings, the diagnosis, and the proposed treatment plan, taking into account the patient’s wishes and input.
You should be asking yourself at this point: what is the definition of appropriate? According to the online version of Merriam-Webster’s Dictionary , when used as an adjective, appropriate means “to meet the requirements of a purpose or situation.” Thus, we start to see that specific records are based on the needs or requirements of each patient. Some professional guidelines would be helpful in this area. Since we, at least here in the United States, don’t have guidelines for taking orthodontic records, let me suggest the following ones that have been used in some academic clinical environments for the last 15 years.
Guideline: A comprehensive medical history must be taken on every patient. This history must include the chief complaint (if known), an appropriate history of the present illness, significant past medical history, a review of systems, significant past dental history, and any pertinent social history, all of which should be appropriate for the age and sex of the patient.
Rationale: The purpose of obtaining a comprehensive medical history rests on the fact that the oral cavity and the dentofacial complex are not treated in a vacuum. Orthodontic patients present themselves for treatment of many ailments; among them are orthodontic, dentofacial orthopedic, and craniomandibular problems. As such, each aspect of the patient’s medical history may give the practitioner important information relative to diagnosing a patient’s condition, formulating a treatment plan, and the mechanotherapeutic approach to be used.
For example, whether there is a chief complaint or not may provide insight into the patient’s perception of his or her orthodontic problem along with any associated ramifications regarding cooperation relating to this perception. A history of the present illness may provide a chronology concerning the rate of development of the orthodontic problem. Ascertaining insight into a patient’s past medical history may reveal pharmacotherapeutic therapy that might have an effect on contemplated orthodontic treatment. A review of systems could easily reveal underlying physical or systemic concerns that have the potential to impact on any proposed therapy or that may require consultation with or referral to other health care providers. One’s past dental history can yield a differential diagnosis, thus rendering guidance in choosing one treatment plan over another. Finally, a social history can provide insight into possible causes for posttreatment rebound. It is incumbent for the orthodontic practitioner to view the patient from the perspective of a physician with a specialty in dentistry and a subspecialty in orthodontics.
Extraoral clinical examination
Guideline: The clinical examination must first address the patient from an extraoral examination. The patient’s gait, stature, and posture should be noted if clinically significant. A frontal analysis of the patient’s soft tissue drape is next followed by a profile analysis. Documentation in the form of a written record or photographic memorialization of this extraoral analysis must be made regardless of whether the examination shows clinically significant findings or that all is within normal limits. A functional analysis of the temporomandibular apparatus must also be completed, noting both normal and abnormal data. An extraoral examination is not “point in time” specific. Both the extraoral and the functional analyses must continuously be reevaluated throughout treatment relative to the potential effect of residual dentofacial growth and development and the treatment being rendered.
Rationale: An analysis of the patient’s facial form and structure will often provide initial diagnostic data for determining a differential diagnosis. Underlying skeletal components are often masked by the patient’s soft tissue drape and as such play a definitive role in treatment planning. Whereas traditional orthodontic diagnosis and treatment planning relied heavily on hard tissue analyses, a more modern approach is to balance the patient’s dentoalveolar and skeletal structures against an esthetic analysis of the overlying soft tissues when developing a treatment plan. Merely conforming to standard deviations relative to the dentition and dentoalveolar support at the expense of how the patient appears in public is not in the best interests of the patient, the public, the practitioner, or the specialty.
A temporomandibular or functional analysis is critical in assessing the dynamics of occlusion. There are many protocols for performing a functional evaluation of a patient. The extent of any functional examination must directly relate to the patient’s chief complaint as well as ongoing evaluations and reevaluations of the patient’s clinical and radiographic findings. Functional problems will, almost always, take priority over diagnosis and treatment planning.
Intraoral clinical examination
Guideline: An intraoral evaluation must consist of an evaluation of the patient’s dentition (erupted and unerupted); occlusion (static and dynamic); the buccal, palatal, pharyngeal, and lingual soft tissues (static and dynamic); and both the hard and soft periodontal supporting structures. Documentation of this intraoral examination in the form of a written record, memorialization via photography or unaltered computer imaging, or through model construction and analysis must be made regardless of whether the examination shows clinically significant findings or that all is within normal limits. An intraoral examination is not “point in time” specific. The hard and soft tissues must continuously be reevaluated throughout treatment, in both static and dynamic modes, relative to the efficacy and effect of the treatment being rendered. The extent of any records or data obtained must directly relate to the patient’s original concern, the orthodontic problem as defined, the treatment undertaken, and the effect of that treatment on the hard and soft intraoral structures.
Rationale: Orthodontic treatment is not merely related to moving teeth from one position to another. The practitioner must have due respect for the adjacent and supporting hard and soft tissues that play a role in the diagnosis of the patient’s problem, the treatment plan for addressing that problem, and the relative ability to maintain the result that is achieved. Because a patient’s dentition is in a constant state of dynamic equilibrium, one must evaluate the hard and soft tissues from both functional and static perspectives. The practitioner should develop an appreciation for the concept that “quality” treatment is best delivered to the patient and achieved by the practitioner through constant and vigilant reevaluation that is obtained and documented for both retrospective and prospective analysis.