LITIGATION AND LEGISLATION
Strategies for improved interdisciplinary
care and communication in orthodontics
Ahmad Abdelkarima and Laurance Jerroldb
Jackson, Miss, and Brooklyn, NY
I
nterdisciplinary care and communications with other
doctors require meticulous management. It is
frequently difficult to oversee a collaborating doc-
tor's work, thoughts, and risk management practices.
Professionals from different disciplines often provide
care at different times and locations, limiting synchro-
nous interaction. Therefore, there could be an increased
2.
potential for liability and injury when working with other
health care providers.
Although an orthodontist is liable for only the services
that he or she provides, the scope of the services in ques-
tion can be difficult to defend if problems arise. In addi-
tion, the provision of interdisciplinary care can be highly
complex and costly for the patient, often contributing
to rising expectations on the patient's part. To improve
patient care and minimize exposure to liability in interdis-
ciplinary care, the following risk management strategies
can be followed and modified as needed.
1. Refer the patient in a timely manner to other health
care providers if needed before orthodontic treat-
ment
If a patient will benefit from the referral to other pro-
3.
viders, it is often best to make the referral before
starting orthodontic treatment. Abnormal clinical or
radiographic findings detected after acquisition of
the diagnostic records should trigger an appropriate
referral. This greatly benefits patient care and can
help to prevent a claim connecting an existing condi-
tion with any subsequent orthodontic care. Appro-
priate referrals must be made in a timely manner. It
is a mistake to wait and see if signs and symptoms
actually result in the patient's injury. Whenever
possible, referral to specialists, rather than general
practitioners, is ideal. The referral should be framed
as a consultation vs a set of instructions.1 It is best
to avoid verbally prescribing treatments, and because
a orthodontic diagnosis and treatment plan.
Department of Orthodontics, School of Dentistry, University of Mississippi,
Jackson, Miss.
b 4.
Chair, Division of Orthodontics; Program Director, Orthodontics and Dentofa-
cial Orthopedics, Department of Dental Medicine, NYU Langone Hospital, Brook-
lyn, NY.
Am J Orthod Dentofacial Orthop 2017;152:717-21
0889-5406/$36.00
Ó 2017.
http://dx.doi.org/10.1016/j.ajodo.2017.08.001
referral letters sometimes do not reach colleagues by
the time of the patient's appointment, a copy could
be given to the patient. It is also beneficial to print
relevant radiographs, include them with the referral
letter, and advise patients to take both with them
to the referred-to doctor.
Follow-up with all referrals
It is an error to refer and forget, especially if the
patient requires immediate attention by another
doctor. Therefore, an effective check-and-balance
system to ensure that referrals are followed up on
should be part of your office protocol. The patient
can neglect, forget, or misunderstand a referral.
The patient thus must appreciate the importance
of the referral, and discussions of this type must
be documented. A quick call from the orthodontist
or a staff member to the patient can go a long
way in these situations. Monitor the progress of
the condition that triggered the referral, and note
any alterations in treatment plan based on the
referral.
Request necessary records from the referring dentist
The referring dentist can often provide valuable
records, such as recent radiographs and history of
trauma to the teeth. Requesting a full periodontal
charting for adult patients from the referring dentist
is a great strategy.2 This establishes correspondence
with the dentist, saves the orthodontist time spent
on periodontal charting, and ensures that the
patient has a dentist providing dental care. It also
ensures that the dentist has performed periodontal
charting and places responsibility on him or her
for diagnosis and management of any periodontal
problems.2 Any significant data obtained from the
referring dentist must be incorporated into the
Assume the role of treatment facilitator in interdis-
ciplinary cases
The orthodontist should help facilitate well-rounded
treatment and document any conversations with
other health care providers regarding a patient.3
717
718
For example, ask the dentist if he or she wants to
provide periodontal and surgical care for the patient,
or if he or she prefers to refer to a specialist. If an
interdisciplinary treatment is planned by a
colleague, such as a restorative dentist or an oral
surgeon, request the treatment plan in writing,
especially in complex and surgical cases. It is essen-
tial to unilaterally question and even reject a misdi-
agnosis or a questionable treatment plan made by
another practitioner. The success of adjunctive
orthodontics in these cases does not preclude an
unsuccessful final outcome. Blindly accepting every
treatment request by other doctors is poor risk
management.4 Therefore, it is best not to participate
in questionable treatment plans unless they are
appropriately modified and a consensus is reached.
In interdisciplinary cases including multiple proced-
ures, inform the patient that the treatment plan can
change depending on the outcome of each step.
5. Ensure that all patients receive necessary prophy-
laxis and checkups
Because fixed orthodontic appliances can interfere
with a patient's oral hygiene efforts, it is essential
that every patient sees his or her dentist or periodon-
tist for regular prophylaxis and checkups. For every
patient, a system must be in place in the orthodontic
office to remind the patient or the parent when these
appointments are due. A quick reminder to patients
about these simple procedures can go a long way,
especially during lengthy treatments or for a patient
with poor oral hygiene.
6. Ensure that adult patients with active or a history of
past periodontal disease are receiving maintenance
It must be stressed to periodontally susceptible
patients or ones with a history of past periodontal
disease that follow-ups with a dentist or specialist
are essential. It is always important to inform the
patient of even mild periodontal disease and to
document it. It is also important to request that
the dentist or the periodontist clear these patients
for treatment and that they be frequently seen
during and after orthodontic treatment.5 The inter-
vals between visits to the periodontist or general
dentist for periodontal maintenance should be
made based on collabroation among the orthodon-
tist, periodontist, and general dentist.
7. Inform the patient's dentist about noncooperation
It is often helpful to write a letter to the patient's
dentist if a patient is uncooperative, because the
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dentist can assist with compliance and understand-
ing. This also increases the dentist's involvement in
the orthodontic treatment, which can increase
patient compliance throughout treatment. One
important area of discussion with a dentist is
when a patient or a parent specifically requests a
narcotic pain medication, especially if the request
is made over the phone. The abuse of prescription
drugs is a prevalent concern, and collaboration
with other health care providers can reduce drug
abuse, diversion, or fraud.
8. Whenever any patient record is requested, obtain a
release from the patient
All original records must be retained, and only
copies should be provided. Before any records are
transferred, the patient should sign an authoriza-
tion to release the records.6 In general, when other
doctors or insurance companies request records,
send only the records that are requested. If unnec-
essary, be careful about releasing sensitive infor-
mation. With the release of any patient
information, consider the “need-to-know” test.
This includes asking who needs to know, why
they need to know, and which information they
need to know. Few situations warrant the release
of information without the patient's consent,
such as a police request or court order. When in
doubt, discuss this with legal counsel. If a patient
is transferring to another orthodontist, one may
choose in specific circumstances to print the
records and give them to the patient or parent,
rather than mailing them to the new orthodontist.
9. Use electronic communications with greatest
caution
Discussing mutual patients and treatment plans via
e-mail requires caution. These e-mails should at
the least be encrypted to prevent potential HIPAA
violations. They should also be saved in the
patient's paper or electronic chart. They should
include the minimum possible amount of protected
health information relating to the patient.
Electronic communications such as e-mails are
considered evidence. Therefore, anything written
in e-mails between colleagues is a record, and it
can later be used as evidence to either help or
hurt a practitioner. To all e-mails containing
patient information, the following standard
disclaimer should be added and modified as
needed: “Persons who have received this informa-
tion in error or are not authorized to receive it
Litigation and legislation
must promptly return or dispose of the information
and notify the sender. Those persons are hereby
notified that they are strictly prohibited from
reviewing, forwarding, printing, copying, distrib-
uting, or using this information in any way.”
10. Avoid using tooth numbers and state the name of
the tooth instead
A classic risk avoidance strategy in orthodontics is
not to use the tooth number when requesting irre-
versible procedures such as tooth extractions and
to name the tooth instead. To further reduce the
probability of errors, it is valuable in atypical extrac-
tion requests to underline or highlight the words
permanent or deciduous, maxillary or mandibular,
first or second premolar, and so on. This prevents
errors made by both the orthodontist and the collab-
orating doctor. In the case of transposition or severe
crowding, which can lead to tooth misidentification,
it is valuable to take an extra step and print photo-
graphs and circle or mark the tooth to be extracted.
11. Consult the patient's physician when prescribing
prophylactic antibiotics for infective endocarditis
Prophylactic antibiotics in orthodontic practice
are rarely indicated to prevent infective endocar-
ditis in patients with specific underlying cardiac
conditions. According to the American Dental
Association, they are indicated only in patients
receiving a dental procedure involving “manipu-
lation of gingival tissue” who have specific un-
derlying cardiac conditions (eg, history of
previous infective endocarditis, cardiac valve
replacement, or surgically constructed pulmonary
shunts or conduits).7 Interestingly, the main or-
thodontic procedure postulated to cause a
bacteremia in these patients is the placement of
a separator.8 Whenever in doubt, reasonable
and prudent risk management dictates that a
consultation be made with the patient's physi-
cian or cardiologist to opt for orthodontic bonds
(rather than bands) and, most importantly, to
avoid all procedures that manipulate the gingival
tissues as much as possible. When referring to
another doctor for procedures requiring prophy-
lactic antibiotics, such as extractions, it is valu-
able to include the underlying cardiac condition
in the prescription to remind the collaborating
doctor.
12. Inform patients to monitor abnormalities in the
long term, even if they require no immediate treat-
ment
American Journal of Orthodontics and Dentofacial Orthopedics
719
Patients must be informed of any pathology,
abnormality, or anatomic variation. Another doctor
should not be relied upon to do this, and it is erro-
neous to solely recommend no treatment without
monitoring the abnormalities that do not require
immediate care. Several examples of this include
impacted teeth, tooth wear, degenerative temporo-
mandibular disease, soft tissue calcifications, and
abnormal anatomic variations. It is possible that
complications can arise from these findings in the
long term. Therefore, the patient must be made
aware of these abnormalities, and the supervising
practitioner should monitor them in the long term.
13. Prevent problems associated with dental implants
The placement of implants in a growing child is
contraindicated and can result in infraocclusion.9
In children requiring implants, it is therefore
important to coordinate with the dentist or the
surgeon regarding the appropriate timing of ortho-
dontic treatment and implant placement. Inform
the patient receiving the implants, especially if in
they are in the anterior region, of their limitations.
Patient education pointers include the fact that
implants do not move as adjacent teeth do, and
that the overall outcome might not be ideal
regarding tooth color, shape, position, and gingival
appearance. It should not be assumed that the
clinician placing or restoring the implant has
provided this basic information.
14. In adjunctive orthodontics to redistribute spaces,
inform the patient that the final outcome may
not be ideal
Adjunctive orthodontic treatment aiming to redis-
tribute spaces before placing crowns may or may
not result in restorative work that satisfies the
patient regarding the shape, color, and occlusion
of the crowns. The cosmetic expectations of
patients are currently quite high. It is therefore
valuable to inform the patient of any esthetic
limitations especially when subsequent restora-
tions are sought for cosmetic purposes. The restor-
ative dentist or prosthodontist might not have
presented this information to the patient. Be sure
to document all discussions that take place.
15. Inform patients that existing dental work may
need to be redone after orthodontic treatment
Patients with existing crowns or veneers, remov-
able dentures, large restorations, or radiographic
evidence of questionable obturation on
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endodontically treated teeth may require retreat-
ment of these procedures after orthodontic treat-
ment. This is either due to a change in occlusion
or gingival margins, or from damage during
bonding and debonding of fixed appliances. There-
fore, if this is a potential risk, it should be disclosed
to the patient before the orthodontic treatment,
and the appropriate dental specialist should be
notified if any retreatments are needed.
16. Whenever valuable, request placement of sealants
from the general dentist or pediatric dentist
The latest evidence-based clinical practice guidelines
from the American Dental Association and the Amer-
ican Academy of Pediatric Dentistry suggest that
sealants are effective in preventing and arresting
pit-and-fissure occlusal carious lesions of deciduous
and permanent molars in children and adolescents,
compared with the nonuse of sealants or the use of
fluoride varnishes.10 Therefore, to improve overall
oral hygiene in children receiving orthodontic care,
it is valuable to discuss this information with parents
and request that the dentist place the sealants before
orthodontic treatment is started.
17. Involve the patient's physician or psychologist
when necessary
If an orthodontic patient has a hematological, neuro-
logical, or endocrine disorder, it is frequently benefi-
cial to contact the patient's physician.11 In some
cases, a psychological evaluation is necessary. For
example, a patient dissatisfied with his or her appear-
ance and any proposed orthognathic surgery visual
treatment objective may be suffering from body dys-
morphic disorder. An adult with apparent mental
impairment seeking orthodontic care may benefit
from an appropriate medical professional evaluation
for competence, an essential element of giving
informed consent. Often these vulnerable patients
are uncooperative or unhappy during or after treat-
ment, and appropriate collaboration with physicians
in specific cases could be invaluable before orthodon-
tic care.
18. Manage all accidents promptly, empathetically,
and at no expense to the patient
Accidents can occur in any practice. Examples of ac-
cidents include lip laceration, swallowing or aspira-
tion of appliances, allergic reaction, or caustic
chemical spills. It is expected that an accident during
any procedure is managed skillfully and with the
appropriate medical professional or hospital,
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including patient transportation. Any medical
expenses not covered by insurance should, prefer-
ably, be covered at no expense to the patient. It is
important to be genuinely empathic and to
follow-up with the patient. All accidents must be
documented in detail in both the patient's chart
and a separate accident log. Major emergencies
might require reporting to the state dental board.
19. Educate colleagues on evidence-based orthodon-
tics vs fads in orthodontics
Patients are increasingly exposed to controversial
or erroneous therapies.12 Besides educating
patients on the possible dangers of these fads, it
is valuable to educate colleagues, including the
referring dentist, so that he or she can participate
in patient education about flawed orthodontic
therapies. Conferences with colleagues about the
feasibilities and limitations of orthodontics are
valuable. It is always important to be careful not
to write derogatory comments about a specific
product, instrument, or technique, since this can
be considered defamatory.
20. Avoid faulting other doctors
Although doctors do make mistakes, the extenu-
ating circumstances, such as patient's lack of coop-
eration or self-destructive behavior, are often
unknown. It is therefore important to avoid
defaming other doctors as much as possible and to
avoid writing entries in a patient's chart that suggest
fault of a colleague.6 Truthfulness, sharing, and
documentation of relevant and factual information
suffice without inciting the patient or blaming other
doctors. In contrast, any doctor who displays contin-
ually egregious work should be reported for peer re-
view to the appropriate reviewing agency, for the
protection of the public and the profession.
CONCLUSIONS
Partnerships and communication with other health
care providers are crucial. Interdisciplinary care requires
referrals to other doctors, and these should be made
timely and be followed. Although an orthodontist is
not liable for the actions of another doctor, he or she
must refer a patient to the appropriate doctor with the
requisite skills and knowledge that can serve the patient.
This minimizes claims of negligent referral.
Interdisciplinary care and communication benefit the
patient significantly, but they truly make a difference
when performed effectively and efficiently. Working
with other practitioners who understand the concepts
Litigation and legislation
of risk management reduces overall risk. In addition,
keeping records of discussions, consultations, and refer-
rals involving both patients and doctors is critical. This
frequently necessitates additional paperwork and entries
into the patient chart.
When planning interdisciplinary care, attention
should be paid to the patient as a whole, focusing on
the “outside in,” with the teeth and occlusion coming
last. Being an excellent team player and establishing a
hotline with excellent doctors reduce risks in orthodontic
practice. In summary, during interdisciplinary care and
communication with other doctors, it is essential to be
active and vigilant rather than passively leaving risk
management to others.
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