Dr Yvonne Shaw, Dental Underwriting Policy Lead at Dental Protection, considers some of the risks arising from patients pursuing direct-to-consumer dental care

The growing popularity of adult orthodontic treatment has resulted in increased activity from companies offering orthodontics services directly to patients in many of the countries that Dental Protection has members in.   

A survey by the British Orthodontic Society (BOS) identified that 80% of orthodontists had seen an increase in adult patients seeking orthodontic treatment.¹ The restrictions on practice arising from the COVID-19 pandemic, coupled with patients becoming accustomed to accessing remote healthcare services  may lead to more patients seeing orthodontic treatment through a direct-to-consumer (DTC) approach as an attractive option.  

In the face of increasing professional concerns surrounding DTC orthodontics, the General Dental Council (GDC)² provided initial confirmation that orthodontic work falls within the practice of dentistry and that anyone practising dentistry while not registered could be subject to prosecution for illegal practice.  Dental professionals involved in this work and who were not complying with the GDC Standards for the Dental Team, could put their registration at risk. 

Dental Protection now welcomes the updated statement from the GDC  providing clarification of the standards that apply to those involved in the provision of DTC care.  Of significance, the GDC has highlighted: 

 it is necessary for a full face to face or physical assessment of the patient’s oral health to have taken place to ensure the patient is suitable for orthodontic treatment  

 if a dentist is relying on information from another source, eg another dental professional, to inform their clinical judgment, the judgment rests wholly with the prescribing dentist

 the treating dentist must make and keep full patient records and remains responsible for communicating effectively with patients and ensuring consent is valid

 patients must know the full name of the dental professional responsible for their treatment and be able to make contact with that person.The GDC’s updated position now lays out the clear requirement for patients to have knowledge of and some direct contact with a clinician responsible for the provision of their orthodontic treatment.

Acting in the patient’s best interests

Central to the dentolegal questions that members have posed about DTC services is the risk of harm to patients.  Concerns range from a patient not understanding the implications or limitations of treatment but also the risks relating to the treatment itself, such as:

- Progression of pre-existing dental conditions such as periodontal disease or caries

- Root resorption

- Exacerbation or development of TMJD

- Adverse tooth movement such as creation of anterior or lateral open bites and changes to occlusion

Of course, all the above risks can apply to any course of orthodontic treatment and these types of complications form the basis of some of the claims we deal with. However, the risk of a problem developing, or not being identified at the outset, is likely to be significantly increased if a patient has not had a full clinical examination prior to commencing treatment. The GDC’s advice that currently there is no effective substitute for a physical, clinical examination as the foundation for the full assessment now places a professional duty on clinicians involved in the patient’s orthodontic care to ensure this has taken place.

A question we are often asked is what a clinician should do if they become aware a patient is, or is contemplating, undergoing treatment provided through a DTC practice. In this situation it would be appropriate to make patients aware of the potential risks of proceeding with a course of treatment in the absence of a face-to-face orthodontic examination taking place. To assist in communicating the risks, members may find it helpful to direct patients to Safe Brace, a joint initiative developed by the BOS and the Oral Health Foundation to help educate patients about orthodontic treatment options. In addition, patients can be directed to the GDC information for patients and the public, which now contains specific advice in relation to direct to patient orthodontic services.  

It is also important to consider that patients may fail to disclose they are, or have been, undergoing treatment with aligners obtained directly from a DTC practice. This could impact upon the assessment of a dental problem or provision of dental care where tooth position may not be stable. This may now become a more common scenario due to patients not attending for routine dental care during the COVID-19 pandemic but having proceeded with DTC orthodontic treatment in the interim. Dentists may therefore wish to consider asking specific questions to elicit whether a patient has had any form of dental treatment, including any ‘DIY’ approaches, as part of their assessment process.

Access to records

Another question that arises is how to respond to a request from a patient, or DTC orthodontic provider, to supply written confirmation that a patient is fit to proceed with orthodontic treatment. This is in effect asking a dentist to make a decision on whether or not a patient is suitable for treatment that the practitioner themselves will play no part in planning or delivering.

Even if a patient has attended recently for dental examinations, this does not equate to a patient being fit to proceed with a specific course of orthodontic treatment. It is Dental Protection’s view that it would not be appropriate for a clinician to comment on whether a patient is fit to proceed with orthodontic treatment where they have no involvement in the clinical assessment, treatment planning or provision of that course of treatment.  In this scenario, it would be in the patient’s interests to advise that a clinical examination, with an appropriately trained orthodontic clinician, would be required to ensure all treatment options and specific risks are considered.

However, patients may instead request a copy of their records or provide authority for these to be disclosed to a third party. If the patient has made such a request, and provided a signed form of authority, then the disclosure of information should be dealt with in accordance with data protection legislation. If the records are to be disclosed with a view to dental treatment being provided elsewhere, a courtesy call to the patient confirming receipt of the request would allow a discussion to take place into what treatment the patient is seeking and whether this is in their interests. A clear note of any discussion with the patient regarding what was advised should be recorded in the patient’s records.

Further advice and support

Any members of Dental Protection affected by the issues outlined in this article should contact our dentolegal advice line for further guidance and support.

³GDC, Providing Dental Care Remotely, 24 February 2020
⁴GDC Statement on ‘direct-to-consumer’ orthodontic treatment May 2021